Recognition of the critically ill child

1. Initial Recognition and Evaluation
PICU Team
MUCH
The Critically Ill Child

2. Initial Assessment &
Recognition of critical illness

3. Recognition of critical illness
Why children are different ?
What are the causes of cardiac arrest ?
How to recognize serious illness ?
Contents

4. Recognition of critical illness
Why children are different ?
What are the causes of cardiac arrest ?
How to recognize serious illness ?
Contents

5. Weight
Anatomical factors
Physiological factors
Psychological factors
Children Are Not Young Adults

6. Why Children Are Different ?
Weight
• Scales.
• The Broselow tape.
• Formulas.
▪ 3-13 mo: (Age (mo.) + 9) /2.
▪ 1-6 yr: Age (yr) * 2 + 8.
▪ 7-12 yr: (Age (yr) * 7 - 5) /2.
The Broselow tape

7. Why Children Are Different ?
Anatomical factors
• Airway
▪ Large Occiput and short neck causes
neck flexion and airway narrowing.
▪ Relatively large tongue
▪ The floor of the mouth is easily
compressible.
▪ Infants are obligate nasal breathers.

8. Why Children Are Different ?
Physiological factors
• The infant has a relatively greater
metabolic rate and oxygen consumption
than adults.
• Hb F
• TV is constant.
• The diaphragm is the main respiratory
muscle.

9. Why Children Are Different ?
Psychological factors
• Communication.
• Fear.

10. Recognition of critical illness
Why children are different ?
What are the causes of cardiac arrest ?
How to recognize serious illness ?
Contents

11. Recognition of critical illness
Respiratory Failure
Cardiac Arrest
Circulatory Failure
Lung Disease
Resp. Depression
Muscle/Nerve Disease
Fluid Loss
Fluid Maldistrubtion
Cardiac Disease

12. Recognition of critical illness
Why children are different ?
What are the causes of cardiac arrest ?
How to recognize serious illness ?
Contents

13. How to recognize serious illness ?
Respiratory
Failure
Circ
ulat
ory
Fail
ure
Neu
rolo
gica
l
Fail
ure
? Respiratory Failure
• Airway problems.
• Efficacy of breathing.
• Effects of respiratory inadequacy.
? Circulatory Failure
• Cardiovascular signs.
• Effects of circulatory
inadequacy. ? Neurological Failure
• Neurological function.
• Effects of neurological
failure on other system.
Detect
Potential

14. Components of a Pediatric
Assessment
• Initial assessment
– Pediatric Assessment Triangle (first impression)
– Primary survey (ABCDE assessment)
– Secondary survey
• Vital signs
• Focused history
• Physical examination
• Ongoing assessment

15. Pediatric Assessment Triangle
First Impression
“Across-the-room” assessment
60 seconds or less
No equipment required

16. PAT …. purpose
Sick
Not
Sick
Urgency of further interventions

17. PAT .. components
A
p
p
e
ar
a
n
c
e
B
re
at
hi
n
g
Circulation

18. PAT .. components
A
p
p
e
ar
a
n
c
B
re
at
hi
n
g
Circulation
• Reflects the adequacy of:
– Oxygenation
– Ventilation
– Brain perfusion
– CNS function
Appearance

19. PAT .. components
A
p
p
e
ar
a
n
c
B
re
at
hi
n
g
Circulation
Appearance
• Assessment areas (TICLS):
• Tone (muscle tone)
• Interactivity/mental status
• Consolability
• Look or gaze
• Speech or cry

20. PAT .. components
A
p
p
e
ar
a
n
c
B
re
at
hi
n
g
Circulation
Work of Breathing
• Reflects the adequacy of
• Airway
• Oxygenation
• Ventilation

21. PAT .. components
A
p
p
e
ar
a
n
c
B
re
at
hi
n
g
Circulation
Work of Breathing
• Assessment areas:
• Posture
• Respiratory rate
• Respiratory effort
• Audible sounds

22. PAT .. components
Work of Breathing
Tripod position

23. PAT .. components
A
p
p
e
ar
a
n
c
B
re
at
hi
n
g
Circulation
Circulation
• Reflects the adequacy of
• Cardiac output
• Perfusion of vital organs

24. PAT .. components
A
p
p
e
ar
a
n
c
B
re
at
hi
n
g
Circulation
Circulation
• Assessment areas
• Skin color

25. PAT .. components
Circulation
Mottling

26. PAT … decision
NOT SICK SICK
BLS
ALS
Secondary survey
Repeated Exam
Primary survey

27. Primary survey
• Hands-on assessment
• Purpose
– Determine if life-threatening conditions exist
• Components
– Airway and cervical spine control
– Breathing
– Circulation
– Disability (neurologic status)

28. Potential Respiratory Failure
Breathing
Effects of Respiratory Inadequacy
Airway

29. Primary survey … Airway
• Goal — determine if the airway is patent,
maintainable, or unmaintainable
● Patent — able to be maintained independently
● Maintainable with positioning, suctioning
● Unmaintainable — requires assistance
– Tracheal intubation
– Cricothyrotomy
– Foreign body removal

30. Primary survey … Airway
• If the airway is open, move on to evaluation of
breathing
• If the airway is not open, assess for sounds of
airway compromise
● Snoring
● Stridor
● Wheeze
• If c-spine injury is suspected, manually stabilize
head and neck in a neutral, in-line position

31. Primary survey … Airway
Look in the mouth
– Blood
– Broken teeth
– Gastric contents
– Foreign objects
• Loose teeth
• Gum
• Small toys

32. Primary survey … Airway
• Interventions
– Spinal stabilization as needed for trauma
• By history or physical exam
– Jaw thrust without head-tilt
– Head tilt-chin lift
– Suction
– Reposition
– Removal of foreign body
– Airway adjuncts

33. Primary Survey — Breathing
• Assessment Goals
– Adequate gas exchange with no signs of
hypoxia
– Absence of dyspnea, stridor, and signs of
increased work of breathing

34. Primary Survey — Breathing
• Evaluation of breathing
should take no more than 10
seconds
• Confirm child is breathing
• Determine if breathing is
adequate or inadequate
• If breathing adequate, assess
circulation

35. Efforts of Breathing
Respiratory Rate
Recessions
Alar Nasal Flare
Audible Noises

36. Efforts of Breathing
Age Respiratory Rate
First 2 months 50
2-12 months 40
1-5 Yr 25-30
6-12 Yr 20-25
>12 15-20
Respiratory Rate
Recessions
Alar Nasal Flare
Audible Noises

37. Efforts of Breathing
Respiratory Rate
Recessions
Alar Nasal Flare
Audible Noises

38. Efforts of Breathing
Respiratory Rate
Recessions
Alar Nasal Flare
Audible Noises

39. Efforts of Breathing
Respiratory Rate
Recessions
Alar Nasal Flare
Audible Noises

40. Efforts of Breathing
Respiratory Rate
Recessions
Alar Nasal Flare
Audible Noises

41. Efforts of Breathing
Respiratory Rate
Recessions
Alar Nasal Flare
Audible Noises

42. Efforts of Breathing
Respiratory Rate
Recessions
Alar Nasal Flare
Audible Noises

43. Efforts of Breathing
Respiratory Rate
Recessions
Alar Nasal Flare
Audible Noises

44. Efforts of Breathing
• Manifestations of increased effort of
breathing are absent in:
– Central respiratory depression.
– Neuromuscular diseases
– Exhausted patients.

45. Efficacy of Breathing
• Chest expansion.
• Air entry.
• Pulse Oximetry.
Silent chest is
a pre-terminal
sign

46. Potential Respiratory Failure
Effects of Respiratory Inadequacy
Airway
Breathing

47. Effects of Respiratory
Inadequacy
• Heart rate.
• Skin color.
• Mental status. Silent chest is
a pre-terminal
sign

48. Effects of Respiratory
Inadequacy
Cyanosis is
a pre-terminal
sign
O2 Sat < 85%
in room air is
a serious sign

49. Primary Survey — Breathing
Signs of Respiratory Distress and Respiratory Failure
Respiratory Distress Respiratory Failure
• Nasal flaring
• Inspiratory retractions
• Increased breathing rate
• Increased depth of
breathing
•Restlessness
• Tachycardia
• Grunting
• Stridor
• Cyanosis
• Diminished breath sounds
• Decreased LOC or response
to pain
• Poor skeletal muscle tone
• Inadequate respiratory rate,
effort, or chest excursion
• Tachycardia
• Use of accessory muscles

50. Primary Survey — Breathing
• Interventions
• Suction
• Oxygen
• Airway adjuncts
• Positive-pressure ventilation

51. Potential Circulatory Failure
Cardiovascular Signs
Effects of Cardiovascular Inadequacy

52. Potential Circulatory Failure
Cardiovascular Signs
Effects of Cardiovascular Inadequacy

53. Primary survey … Circulation
• Goals
– Adequate cardiovascular function and
tissue perfusion
– Effective circulating fluid volume
– Normal core body temperature

54. Primary survey … Circulation
• Assessment
– Compare strength and quality of
central and peripheral pulses
– Central pulse
• Infant
– Brachial or femoral artery
• Older child
– Carotid artery

55. Cardiovascular Signs
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

56. Cardiovascular Signs
Age (years) Heart Rate
< 1 110 – 160
1-2 100 – 150
2-5 95 – 140
5-12 80 – 120
>12 60 - 100
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

57. Cardiovascular Signs
Release
Press for 5s
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

58. Primary survey … Circulation

59. Cardiovascular Signs
More than 2 sec CRT with other
signs of shock in a worm child
suggests poor peripheral
perfusion
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

60. Primary survey … Circulation
– Less than 2 seconds = normal
– 3 to 5 seconds = delayed
• Poor perfusion
• Exposure to cool ambient
temperatures
– More than 5 seconds = markedly
delayed
• Suggests shock
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

61. Primary survey … Circulation
Description Grade
Full, bounding, not obliterated with pressure
+ 4
Normal – easily palpated, not easily obliterated with
pressure
+ 3
Difficult to palpate, obliterated with pressure
+ 2
Weak, thready, difficult to palpate
+1
Absent pulse 0
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

62. Cardiovascular Signs
Age (years) SBP (mm Hg)
< 1 70 – 90
1-2 80 – 95
2-5 80 – 100
5-12 90 – 110
>12 100 - 120
> 2 year SBP = 70 + (2 x age in years)
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

63. Cardiovascular Signs
%
o
f
C
o
n
tr
o
l
Vascular
Resistance
Cardiac Output
Blood Pressure
25% 50%
% Plasma Loss
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

64. Primary survey … Circulation
Skin color
• Pink
• Pale
• Blue/cyanotic
• Mottled
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

65. Primary survey … Circulation
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

66. Primary survey … Circulation
– Skin temperature
– Skin moisture
– Skin turgor
Heart Rate
Capillary Refill
Pulse Volume
Blood Pressure
Skin

67. Primary survey … Circulation
• Interventions
– Oxygen
– Position
– Chest compressions
– Bleeding control
– Defibrillation

68. Potential Circulatory Failure
Cardiovascular Signs
Effects of Cardiovascular Inadequacy

69. Effects of Circulatory
Inadequacy
• Heart rate.
• Urine output.
• Skin color.
• Mental status.

70. Cardiac Vs Respiratory ?
• Cyanosis despite O2
• Marked tachycardia
• Quiet tachypnea
• Raised jugular venous pressure
• Gallop rhythm / murmur
• Enlarged liver (? ptosed)
• Absent/ weak femoral pulses

71. Potential Central Neurological Failure
Neurological Function
Effects of Neurological Inadequacy

72. Potential Central Neurological Failure
Neurological Function
Effects of Neurological Inadequacy

73. Neurological Function
Conscious level
Posture
Pupillary signs
Other signs

74. Neurological Function
Alert
Responds to Voice
Responds only to Pain
Unresponsive to all stimuli
Conscious level
Posture
Pupillary signs
Other signs

75. Neurological Function
Eye opening
Spontaneously 4
To verbal stimuli 3
To pain 2
No response to pain 1
Localises to pain 5
Withdraws from pain 4
Abnormal flexion to pain 3
(decorticate)
Abnormal extension to 2
pain (decerebrate)
No response to pain 1
Modified GCS
Conscious level
Posture
Pupillary signs
Other signs

76. Neurological Function
decorticat
e
decerebrat
e
Conscious level
Posture
Pupillary signs
Other signs

77. Neurological Function
• Unequal pupils is a medical
emergency.
• Fixed dilated pupils are not
always due to brain death
Conscious level
Posture
Pupillary signs
Other signs

78. Neurological Function
Conscious level
Posture
Pupillary signs
Other signs
• Distractibility by parent.
• Eye contact (>2 months of age).
• Speech / cry.
• Motor activity.
• Abnormal muscle tone.
• Abnormal reflexes.

79. Potential Central Neurological Failure
Neurological Function
Effects of Neurological Inadequacy

80. Effects of Neurological
Inadequacy
• Abnormal Breathing patterns.
• Increased blood pressure with
sinus bradycardia.
• CPP = MAP - ICP

81. Initial management
(Immediate Life Support)
?

82. Thank You!