PALS primary assessement and pediatric emergencies

1. Physical assessement of a sick child
Dr. Shafini Beryl

2. Disclaimer
• This presentation covers only a snapshot of
the subjects presented- each topic could be
lecture of its own!
• You are encouraged to do further research
into each topic.
• Not all pediatric emergencies are covered in
this presentation

3. Pediatric emergencies
1. Respiratory emergencies
– Upper airway obstruction(croup, epiglottis,
foreign body obstruction)
– Lower airway obstruction(Asthma)
– Pneumonia
2. Circulatory emergencies- shock
3. Cardiac emergencies- SVT, Cardiac failure
4. CNS- Coma, seizures
5. Infections- Sepsis, meningitis, encephalitis
6. Trauma
7. Poisoning.....and so on ....

4. Aim of the presentation
• Recognize and manage life threats based on simple assessment findings
for a child while awaiting additional emergency response.

5. Important considerations
• Differs from adult assessment
• Have age-appropriate equipment, review age-appropriate vital signs
• Sudden illness and medical emergencies are common in children and
infants.
• Anatomical differences exist between adults and children.

6. • Managing a pediatric emergency can be one of the most
stressful situations you face as an EMR.
– Calm and professional.
– Unless you are prepared, your anxiety and fear may interfere with your
ability to deliver proper care.
– The parents can be either allies or a potential problem.
– Talk to both the parents and the child as much as possible.
– Try to develop a rapport with the child.

7. ASSESSMENT

8. Steps in structured assessement

9. The pediatric assessment triangle
• The PAT helps you quickly form a general impression of the child
using only your senses of sight and hearing.
• Can be used to assess a child from a distance

10. INITIAL IMPRESSION: A-B-C

11. Appearance
Lethargic
Active
Decreased interactiveness
Interactive child

12. Appearance
Gaze abnormality- strabismus
Inconsolable cry

13. PAT-Work of breathing

14. Work of breathing
Intercostal retraction
subcostal retraction
substernal retraction

15. PAT-Circulation

16. Circulation
Pallor Mottling Cyanosis

17. Initial impression- Pediatric assessement triangle(PAT)
UNRESPONSIVE
APNEA/GASPING
CYANOSIS
Life threatening conditions

18. If Life-threatening on initial impression
• Activate the Emergency response system
• Initiate life-saving measures based on the scope of practice
￭ Open The Airway and provide oxygen
￭ Attach monitor and AED
￭ Check for pulse
￭ Provide CPR if needed (central pulse absent/<60)
￭ I.V. / IO Access, Fluids, and medications
•Proceed for further evaluation after initial stabilization/ all parameters
normal

19. MANAGEMENT

20. How to proceed?

21. Initial impression
PAT

22. SICK or NOT SICK
• The ‘PAT’ functions as a rapid initial
assessement to determine, “sick” or
“not sick” and should be
immediately followed by the
ABCDE’s

23. Further evaluation- Primary assessement

24. Pediatric anatomy- Children are not small
adults
• A child’s airway is
smaller in relation to
the rest of the body
compared to an
adult’s airway.
• A child’s tongue is
relatively larger than
an adult’s.

25. AIRWAY- Assessement

26. AIRWAY- Assessement

27. Airway- Intervention

28. Airway Intervention- simple measures

29. Airway intervention- advanced

30. BREATHING- Assessement
1. Respiratory rate
2. Work of breathing
3. Chest wall expansion
4. Auscultation- added sounds
5. Pulse oximetry

31. BREATHING-RR
WHO-IMCI

32. BREATHING-WOB, Additional sounds
• Nasal flaring
• Retractions
• Grunting
• Head nodding
• See saw respiration

33. Pulse oximetry
• Detects before apparent cycnosis
• SpO2 >94% in room air
• Limited in poor perfusion

34. BREATHING-Identification
• Severity
• Anatomical site

35. BREATHING- Severity

36. BREATHING- Anatomical site
• Upper airway obstruction
• Lower airway obstruction
• Lung parenchymal disorders
• Disorder of breathing

37. BREATHING- Anatomical site

38. Upper airway obstruction

39. Respiratory emergencies- fundamental of
management
• Keep the child in the position of comfort and minimize agitation.
• Suctioning of nose or mouth if secretions are present.
• Provide humidified oxygen, preferably with high concentration delivery
device e.g., Head box (for infants less than 6 mo), Oxymask or non-
rebreathing mask (for older children).
• Monitor heart rate, respiratory rate, blood pressure and SpO2.
• Establish vascular access

40. Croup- Mx

41. Foreign body

42. Anaphylaxis
• Acute onset of an illness (minutes
to several hours) involving the
skin, mucosal tissue, or both and
at least one of the following:
1.Respiratory compromise
2.Reduced blood pressure
3.Persistent GI symptoms
GIVE Adrenaline (The wonder drug):
• 0.01 ml/kg (1:1000) IM
(maximum dose 0.5 ml).

43. Lower airway obstruction

44. Bronchiolitis- Mx

45. Asthma - Mx

47. Respiration-Intervention

48. Circulation- assessment
1. Heart rate and rhythm
2. Peripheral and central pulses
3. Capillary refill time
4. Skin and peripheries
5. Blood pressure
6. Urine output

49. Circulation- HR

50. Circulation- Pulses
• Central pulses- Carotid in older
children. Femoral and axillary in
infants
• Peripheral - radial, temporal,
posterior tibial
• Pulses become weak in shock

51. Circulation - CRT
• Normal: 2-3 seconds

52. Skin perfusion- colour and temperature
• Decreased cardiac output results in decreased perfusion and oxygenation
to the extremities
• Look for
– cold extremities
– mottling
– cyanosis
– pallor

53. Blood pressure

54. Blood pressure
• use appropriate size cuff

55. Urine output
• Indirect indicator of adequate circulation
• Indicates kidney perfusion and function
• Infants: 1.5-2ml/kg/hr
• Children : 1ml/kg/ hr

56. Circulatory insufficiency- categorization by
severity
Compensated
• Tachycardia
• Cool peripheries
• Delayed CRT
• Weak peripheral pulses
• Narrow pulse pressure
• Oliguria
• NORMAL BP
Hypotensive
• All the above plus
• BP below 5th centile
• Change in mental status

57. Shock- Fundamentals of management
• Allow the child to remain in the most comfortable position.
• Start high flow oxygen
• Support ventilation: CPAP or invasive mechanical ventilation.
• Establish vascular access for fluid resuscitation and administration of
medications.
• Give rapid fluid bolus(NS or RL) of 20 ml/kg over 5 to 10 min

58. Shock- Fundamentals of management
• Monitor vitals and perform frequent assessment to determine the
response to therapy.
• Take initial blood samples. Identify and correct hypoglycemia and
hypocalcemia early.
• Give medications e.g., vasoactive agents (dopamine, epinephrine),
dextrose, calcium, antibiotics, analgesic. Give 1st dose of antibiotic in
septic shock preferably within 1st hour of presentation.
• Refer to pediatric facility with intensive care monitoring for further
management.

59. Based on etiology
• Hypotensive shock
• Distributive shock
• Cardiogenic shock
• Obstructive shock

60. Shock-Interventions

61. Disability
• Quick evaluation of the neurological function - AVPU
• Assess the third vital organ- the brain
• Brain injury may be primary(direct-trauma, meningitis, seizures) or
secondary (hypoxia, shock)
• Severity and duration of hypoxia will give rise to different signs
• Bedside glucose estimation is a must

62. Disability

63. Seizure- Management

64. Seizure- Management

65. Seizure- Management

66. Exposure
• Undress as appropriate, avoid exposure to cold
• Look for deformities/ bruises/ bleeds
• Take care of cervical spine in case of emergencies
• Record temperature and correct hypo and hyperthermia

67. Revision-Primary survey

68. Secondary survey
• Focussed history- SAMPLE
• Physical examination

69. CASE DISCUSSION

70. CASE 1
• 8 year old child
– Cough x 1 day
– Breathing difficulty since
evening and rapidly worsening,
even has difficulty in speaking
– Past history of nebulisations ,
not on any regular MDI
• Mother having history of asthma

71. Primary assessment

72. Identify and treat
• Respiratory failure
• Lower airway disease
• Status asthmaticus

73. Case 2
• 3 year old boy child
– Fever x 3 day high grade
– No rashes
– Decrease activity 1 day
– No past significant history

74. Primary assessement

75. Identiify and treat
• Hypotensive shock
• Probable Sepsis

76. Case 3
• 1 year old male child
– Diarrhea x 3 day , 8- 10
episodes/day
– Vomiting x 4 episodes non
bilious
– Decrease activity 1 day
– On bottle feeding
– No past significant history

77. Primary assessement

78. • Hypotensive shock
• AGE with severe dehydration

79. Left out- Pediatric trauma and poisoning

81. Do you have any questions?
THANK YOU FOR YOUR ATTENTION