Pediatrics notes about "The critically ill child". These notes were published in 2018. You can download them also from - Telegram: https://t.me/pediatric_notes_2018 - Mediafire: http://www.mediafire.com/folder/u5u60m184t9z7/Pediatric_Notes_2018

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Kareem Alnakeeb
The critically ill child
(Initial evaluation and management)
1. Why children are different?
- Children are NOT young adults.
- They are different in:
(Weight, Anatomical factors, Physiological factors, Psychological factors).
Weight: • Scales
• The Broselow Tape → Most accurate
it uses the height (or length) of the child to estimate weight
• Formulas;
- 3-13 months: Weight (kg) = [ Age(months)+ 9] /2
- 1-6 years: Weight (kg) = [ Age(years) x 2 ] + 8
- 7-12 years: Weight (kg) = { [ Age(years) x 7 ] - 5 } /2
Anatomical factors:
(Airway)
- Large occiput and short neck → neck flexion and airway narrowing
- Relatively large tongue
(Most common cause of airway obstruction in the unconscious
pediatric victim is the tongue)
- The floor of the mouth is easily compressible
- Infants are obligate nasal breathers (Up to age of 6 months)
Physiological factors: - The infant has a relatively greater metabolic rate and oxygen
consumption than adults
- Hb F → has higher affinity for O2 than HbA1 & HbA2
- Tidal Volume (Air that enters lung with each quiet inspiration) is constant
o the only way to ↑ minute ventilation is to ↑ RR
o So, Tachypnea is the earliest sign of respiratory distress
- The diaphragm is the main respiratory muscle → easily fatigable
Psychological factors: - Communication
- Fear e.g. white coat hypertension
(++ Sympathetic → ↑HR, RR, sweating→ Overlap with the disease)
Minutevolume=TidalvolumexRespiratoryrate
Recognition of critical illness:

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2. What is cardiac arrest?
- Absence of palpable central pulse in;
 Carotid  in older children & adults
 Brachial / Femoral  in young children
3. What are the causes of cardiac arrest?
• Respiratory failure
(Hypoxemia is the most common cause of cardiac arrest in children)
• Circulatory failure
• Neurological failure
4. How to recognize serious illness?
Respiratory failure: 1. Airway problems
2. Efficacy of breathing
3. Effects of respiratory inadequacy
Circulatory failure: 1. Cardiovascular signs
2. Effects of circulatory inadequacy
Neurological failure: 1. Neurological function
2. Effects of neurological failure on other systems
The assessment of a seriously unwell child involves the following:
• Pediatric assessment triangle (PAT) (first impression)
• primary survey (ABCDE assessment)
• Secondary survey
- Vital signs
- Focused history
- Detailed physical examination
• Ongoing assessment.
Components of a pediatric initial assessment:

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A. Pediatric Assessment Triangle (first impression)
1. (Across-the-room) assessment
2. No equipment required
3. 60 seconds or less
 PAT purpose:
• To classify children into:
- Sick/Not sick
- Urgency of further investigations
 PAT decision
 Sick →
(Basic Life Support, Advanced Life Support)
 Not Sick →
(Primary survey, secondary survey, Repeated exam)
 PAT components:
1. Appearance
2. Breathing
3. Circulation
PAT components Reflect the adequacy of Assessment areas
1. Appearance - Oxygenation
- Ventilation
- Brain perfusion
- CNS function
Mnemonic: TICLS
- Tone (muscle tone)
- Interactivity/mental status
- Consolability (ability to calm the child)
- Look or gaze
- Speech or cry
2. Work of
Breathing
- Airway
- Oxygenation
- Ventilation
- Posture (e.g. Tripod or Sniffing position)
- Respiratory rate
- Respiratory effort
- Audible sounds
3. Circulation - Cardiac output
- Perfusion of vital organs
- Skin color
e.g. pallor, mottling and cyanosis

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B. Primary survey: (ABCDE assessment)
• Hands-on assessment
 Purpose: determine if life-threatening conditions exist
 Components;
- Airway and cervical spine control
- Breathing
- Circulation
- Disability (neurologic status)
- Exposure
I. Potential respiratory failure:
(Airway, Breathing, Effects of respiratory inadequacy)
 Airway
- 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
 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 & neck in a neutral, in-line position
- Look in the mouth:
 Blood
 Broken teeth
 Gastric contents
 Foreign objects (loose teeth/gum/small toys)
Goals:

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 Spinal stabilization as needed for trauma (by history or physical examination)
 Jaw thrust without head tilt
 Suction
 Reposition
 Removal of foreign body
 Airway adjuncts
 Breathing
1. Adequate gas exchange with no signs of hypoxia
2. Absence of dyspnea, stridor, and signs of increased work of breathing
o Evaluation of breathing should take no more than 10 seconds
o Confirm child is breathing
o Breathing (Effort – Efficacy – Effect on other organs)
 If breathing adequate→ assess circulation.
A. Respiratory Rate:
-  RR with age
- In cardiac arrest  Early: ↑RR, Late: RR
- Normal RR in presence of other signs of
respiratory distress is a Bad sign.
B. Alar nasal flare: Dilatation of air passages →  Resistance → effort of breathing
C. Recessions:
- Indrawing of lower part of thoracic cage
- Represent the use of accessory muscles to help in breathing
D. Audible Noises
i. Stridor:
- Inspiratory sound that is usually indicating upper airway obstruction
ii. Wheeze:
- Expiratory sound that is usually indicating lower airway obstruction
iii. Grunting:
- Forced expiration against a partially closed glottis to increase the end expiratory
pressure to assist gas exchange and prevent alveolar collapse
- It indicates alveolar disease.
Age Respiratory Rate
First 2 months 50
2-12 months 40
1-5 years 25-30
6-12 years 20-25
>12 years 15-20
Interventions:
Goals:
1. Efforts of breathing:

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 Manifestations of increased effort of breathing are Absent in:
1. Central respiratory depression e.g. Morphine
2. Neuromuscular diseases e.g. spinal muscular atrophy or muscular dystrophy
3. Exhausted patients (with imminent respiratory arrest).
• Chest expansion
• Air entry (Note: Silent chest is a pre-terminal sign)
• Pulse oximetry (Note: Hypoxemia is a danger sign)
Early Late
A. Mental status Irritable “inconsolable” unresponsive
B. Heart rate ↑ 
C. Skin color - Pallor
- O2 saturation < 85% in room air is
a serious sign
- Cyanosis is a late & pre-terminal
sign
Respiratory distress Respiratory failure
• ↑ Respiratory Rate & depth of breathing
• Nasal flaring
• Inspiratory retractions
• Grunting / Stridor
• Restlessness
• Tachycardia
•  Respiratory rate, effort, or chest excursion
• Cyanosis
• Use of accessory muscles
•  breath sounds
•  skeletal tone
•  conscious level or response to pain
• Bradycardia
• Suction
• Oxygen
• Airway adjuncts
• Positive-pressure ventilation
2. Efficacy of breathing:
3. Effects of respiratory inadequacy:
Signs of Respiratory distress & Respiratory failure:
Interventions:

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II. Potential Circulatory failure
(Cardiovascular signs, Effects of cardiovascular inadequacy)
 Cardiovascular signs
- Adequate cardiovascular function and tissue perfusion
- Effective circulating fluid volume
- Normal core body temperature
- Compare strength and quality of central and peripheral pulses
- Central pulse:
► Infant → Brachial or femoral
► Older child → carotid artery

1. Heart rate:
-  HR with age
- In cardiac arrest  Early: ↑HR, Late: HR
- Normal HR in presence of other signs of circulatory insufficiency is a Bad prognostic sign.
2. Capillary refill time (CRT):
 Normal refill time: < 2 seconds
 Slow refill time (> 2 seconds) indicates poor peripheral perfusion.
- CRT is useful in the warm child & in presence of other signs of shock.
 Delayed refill time (3-5 seconds) indicates:
(poor perfusion, Exposure to cool ambient temperatures).
 Markedly delayed refill time (>5 seconds) indicates Shock.
Age (years) Heart Rate
< 1 110-160
1-2 100-150
2-5 95-140
5-12 80-120
>12 60-100
Goals:
Assessment:
Cardiovascular signs:

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3. Pulse volume
Grade Description
+4 Full, bounding; not obliterated with pressure
+3 Normal - easily palpated; not easily obliterated with pressure
+2 Difficult to palpate, obliterated with pressure
+1 Thready and weak, Difficult to palpate
0 Absent
4. Blood pressure
- ↑ BP with age
- >2 years: Minimum SBP = 70+(2x age in years)
- Note: Hypotension is a late & pre-terminal sign
- Absence of hypotension does NOT exclude shock, so shock can occur in normal BP.
5. Skin
- Skin color: Pink, pale, blue (cyanotic) or mottled.
- Skin temperature
- Skin moisture
- Skin turgor
• Oxygen
• Position
• Chest compression
• Bleeding control
• Defibrillation
Age (years) SBP (mmHg)
< 1 70-90
1-2 80-95
2-5 80-100
5-12 90-110
>12 100-120
Interventions:

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 Effects of cardiovascular inadequacy 
1. Heart rate
2. Respiratory rate:
► Early → ↑ without recessions “Quiet tachypnea”
► Late → 
3. Urine output:  (In infants: < 1 ml/kg/h, In children: < 0.5 ml/kg/h)
4. Skin color: Cyanosis is a pre-terminal sign
5. Mental status:
► Early → irritable
► Late → unresponsive
There is a clear overlap between respiratory & circulatory failure.
- The following signs are more in favor of a circulatory condition:
1) Cyanosis despite supplied O2
2) Quiet tachypnea (tachypnea without recessions)
3) Marked tachycardia out of proportion to respiratory distress
4) Gallop rhythm / murmur
5) Raised jugular venous pressure
6) Enlarged liver (beware of posted liver)
7) Absent/ weak femoral pulses
III. Potential Neurological failure
(Neurological function, Effects of neurological failure on other systems)
 Neurological function
1) Conscious level:
 AVPU score: A = Alert
V = Responding to voice
P = Responding to pain
U = Unresponsive to all stimuli

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 Modified Glasgow Coma Score (GCS):
Child Infant Score
Eye opening (1-4)
Spontaneous Spontaneous 4
To speech To speech 3
To pain To pain 2
No response No response 1
Verbal response (1-5)
Oriented Coos, babbles, fixes, follows 5
Confused Irritable, cries but consolable 4
Inappropriate words Cries to pain, inconsolable 3
Incomprehensible sounds Moans to pain 2
No response No response 1
Motor response (1-6)
Obeys Moves spontaneously 6
Localizes Withdraws to touch 5
Withdraws Withdraws from pain 4
Decorticate to pain Decorticate to pain 3
Decerebrate to pain Decerebrate to pain 2
No response No response 1
 The least score is 3/15; the best is 15/15.
 If GCS is < 8, airway management should be considered
2) Posture:
- Hypotonia in a previously well is a sign of serious illness
- Stiff posturing: is a sign of serious brain dysfunction
► Decorticate (flexed arms, extended legs)
► Decerebrate (extended arms, extended legs)
- Stiffing dog position: Overextension of the neck
► upper airway obstruction e.g. epiglottitis
- Opisthotonus → meningeal irritation
3) Pupillary signs:
- Unequal pupils is a medical emergency
- Dilated fixed pupils are not always due to brain death

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4) Other signs: (TICLS)
• Abnormal muscle tone
• Abnormal reflexes
• Motor activity
• Distractibility by parents
• Eye contact (> 2 months of age)
• Speech/Cry
 Effects of neurological failure on other systems
- Abnormal breathing patterns e.g. Cheyne Stokes respirations
- Increased blood pressure with sinus bradycardia (Cushing's response)
o Indicates compression of the medulla oblongata caused by herniation of the cerebellar
tonsils through the foramen magnum.
o So, ↑ ICP → ↑ MAP → To keep CPP Constant
 Late & pre-terminal signs:
- Silent chest
- Cyanosis
- Hypotension
CerebralPerfusionPressure(CPP)=MeanArterialPressure(MAP)-IntracranialPressure(ICP)
 Cushing's triad: a sign of increase intracranial pressure (ICP)
• Hypertension
• Bradycardia
• Respiratory depression
 Cushing's response:
• Hypertension
• Bradycardia