pediatric essential care

1. Recognizing and Stabilizing the-seriously-ill-child

2. Objectives
1.Triage all infants and children in structured way to
recognize the severity of illness.
 Those with emergency signs.
 Those with priority signs.
 Those who are non-urgent cases.
2. Prepare a management plan to stabilize seriously ill child
in emergency.

3. The core concept
Infections
Trauma
Toxins
Congenital,
metabolic
Cardiac
Physiological
Impairment
Pathways
Respiratory
Circulatory
Neurological
Cardiac
Arrest

4. Triaging:
Sorting of infants and children to rapidly screen sick child for
prioritizing management.

5. Management process of the sick child contd..
Structured way of management of sick child.
Step 1-
a. Proceed with PAT/ABCDE:
Look for –Emergency signs - If present, then urgent emergency
treatment including CPR.
b. If no emergency sign:
Look for Priority signs- if present, then immediate assessment and
treatment.
c. If no emergency or priority signs
Treat as Non-urgent cases and can be wait in queue.

6. Emergency Signs
• Obstructed breathing
• Severe respiratory distress
• Central cyanosis
• Signs of shock
Cold hands
CRT > 3 seconds
Weak, fast pulse
• Coma
• Convulsions
• Signs of severe dehydration: any two
Lethargic, sunken eyes, very slow return after skin pinching

7. Priority signs
• Tiny baby
• Fever
• Trauma or other urgent surgical conditions
• Severe pallor
• Poisoning
• Severe pain
• Respiratory distress
• Restless, continuously irritable or lethargic
• Referral (urgent)
• Severe wasting (acute malnutrition)
• Oedema of both feet
• Major burns

8. Management process of the sick child contd..
Step 2: Once emergency signs identified; prompt emergency
treatment to stabilize the condition of the child.
Step 3: After stabilization; focused history and perform secondary
examination relevant to the presenting problems.
Step 4: Perform relevant laboratory investigations.

9. Management process of the sick child contd..
Step 5: List possible diagnoses, more than one diagnoses or clinical
problems is possible.
Step 6: After deciding the main diagnosis and any secondary diagnoses
or problems, treatment is to be started accordingly and closely
monitored for response to treatment.
Step 7: Outcome: Discharge, admission, refer

10. How to identify seriously ill child (Triage)
Identified from conducting a rapid primary survey in a structured way:
Keep in mind the PAT/ABCDE steps.
Pediatric Assessment Triangle:
Appearance, Breathing and Circulation
ABCDE:
A: Airway
B: Breathing
C: Circulation
D: Disability: Coma, Convulsion and Dehydration
E: Exposure: Expose skin for rashes, temperature, signs of trauma

11. Structured approach to a sick child
• Initial impression
• Primary assessment
• Secondary assessment
• Diagnostic tests

12. The initial impression (PAT assessment)

13. Possible scenario after PAT
Start CPR
Child Unresponsive
Assess Breathing and Pulse
Airway Stabilization
Positive Pressure Ventilation
Pulse<60/min with poor Perfusion
despite adequate Oxygenation and Ventilation
Proceed with Primary Assessment
Pediatric Assessment Triangle (Appearance, Breathing, Circulation)
No breathing only gasping, Pulse Present Severe compromise of Airway, Breathing or
Circulation
Yes
No
Yes
Yes
No
No
Breathing and Pulse present

14. Airway and Breathing
 Is the child breathing? Look, listen and feel for air
movement.
 Is the airway obstructed? (due to tongue fall, foreign body,
croup or neck swelling)
 Is the child blue (centrally cyanosed)? Pulse oximeter is used
to measure the oxygen saturation.
 Does the child have severe respiratory distress? (Very fast
breathing, severe chest indrawing, using accessary muscles
of respiration)

15. Initial management
• Clear the airway. Gentle suctioning if secretions, blood and
vomitus.
• If complete airway obstruction; such as choking, use Heimlich
maneuver to relieve choking from a foreign body.
• Give oxygen by using an appropriate oxygen delivering device.
• If not breathing, give rescue breath via an AMBU bag.

16. Circulation
Decide whether the child is in shock or impaired circulation.
• Cold hands
• Capillary refill time longer than 2 seconds in sick children and 3
seconds in neonate.
• Pulse weak and fast (Check radial pulse. May check brachial or
femoral pulse in infant.)
• If the child has impaired circulation, check if the child malnourished?
Hypotension is a late feature of cardiovascular dysfunction signaling the failure
of the compensatory mechanism

17. Initial Management
• If no central or carotid pulse, commence CPR immediately.
• If inadequate perfusion:
obtain intravenous or intraosseous access as soon as possible
 infuse Normal saline bolus at 20 ml/kg.

18. Coma/ conscious level
Rapid assessment of conscious level can be made by assigning the
patient to one of the AVPU categories:
• A- Alert
• V- responds to Voice (lethargic)
• P- responds to Pain (coma)
• U- Unresponsive (coma)
scale P or U indicate emergency sign.
The best immediate treatment for patients with a primary cerebral
condition is stabilization of the airway, breathing and circulation.

19. Convulsion
Ask and look for convulsion:
If the child is convulsing, this is an emergency, requiring
immediate treatment.
Initial Management:
• Manage airway
• Position the child in left lateral position.
• Check and correct hypoglycemia.
• If convulsions continue, start anticonvulsants
 give I/V calcium in young infants before anticonvulsant (<3months)

20. Dehydration
Ask whether the child is having diarrhea. If yes, assess for signs of
severe dehydration- any two of;
• Is the child lethargic or unconscious?
• Is the child having sunken eyes?
• Is the skin pinch going back very slowly?
Initial Management:
• If child is not severely malnourished, Insert I/V line and begin giving
fluids rapidly according to severe dehydration plan.
• If the child is severely malnourished, do not start I/V immediately.
Proceed immediately to full assessment and treatment.

21. Exposure
• Expose skin and look for any rashes, bite mark or injury, clues
for poisoning.
• Take temperature.
That gives clues to diagnosis for further management.
The Need for Frequent reassessment
After providing emergency treatment, the child should be re-
assessed using the complete ABCDE sequence.

22. Management plan for seriously ill child
Treat Do not move neck if cervical spine
injury possible. Keep the child warm
Airway and
Breathing
No breathing
OR
Obstructed
breathing OR
Central cyanosis
OR
Severe
respiratory
distress
Any sign
positive
• If not breathing or gasping:
 Rule out neck trauma
 Manage airway
 Start BLS
• If FB aspiration:
 Manage airway in choking
child
• If NO FB aspiration:
 Manage airway
 Give O2
 Make sure child is warm

23. Management plan for seriously ill child
Circulation Cold hand
with CRT > 3
seconds,
Weak and fast
pulse
If positive • If the child has any bleeding
apply pressure to stop
bleeding. Do not use
tourniquet
• Give O2
• Make sure child is warm
• If NO acute malnutrition, If
lethargic or unconscious:
 Insert IV line and give fluid
 Give IV glucose
If NOT lethargic or unconscious:
 Give glucose orally or via NG
tube
 Proceed immediately to full
assessment and treat

24. Management plan for seriously ill child
Coma/
convulsing
Coma OR
Convulsing
If Coma OR
Convulsing
• Manage airway
• Position unconscious child (stabilize
first if head or neck trauma)
• Give O2
• Check and correct hypoglycemia
• Give IV Ca if infants < 3 months
• Give anticonvulsant If convulsions
continue
• Make sure child is warm

25. Management plan for seriously ill child
Treat
Severe
dehydratio
n (Only
child with
diarrhea)
Diarrhe
a plus
any
two of
these
Diarrhea
plus two
signs
positive
• If NO severe acute malnutrition:
 Insert IV line and give fluid
(NS/RL) rapidly
• If severe acute malnutrition:
 Do not give fluid, give ORS
(ReSoMal): 5 ml/kg/every 30
minutes for 2 hours
 Proceed immediately to full
assessment and treatment

26. Management plan for seriously ill child
If there are no emergency signs look for priority signs: these children need
prompt assessment and treatment
Priority signs
• Tiny baby (< months)
• High fever
• Trauma or other
urgent surgical
condition
• Severe pallor
• Poisoning
• Severe pain
• Respiratory distress
• Restless, continuously
crying
• Irritable or lethargic
• Referral
• Visible severe wasting
• Oedema of both feet
• Major burns
• If not able to insert
peripheral IV, insert
external jugular or IO line
• If a child has trauma or
other surgical problems,
get surgical help or
follow surgical guidelines

27. Physiological classification
 Stable
 Respiratory distress
 Respiratory failure
 Compensated shock
 Hypotensive shock
 CNS dysfunction
 Cardiopulmonary failure

28. SAMPLE HISTORY: SECONDARY SURVEY
• Sign/symptoms
• Allergies
• Medications
• Past medical history
• Last food or liquid
• Events before injury/illness

29. Detailed physical examination and investigation:
• CVS:…………………………………………….
• Respiratory system:…………………………………….
• CNS:……………………………………………….
• Abdominal :………………………………………..
• Investigation: ……………………………………………………

30. •Any Question?

31. Summary
• Summarize by showing the pediatric emergency triage form