ASSESSING SEVERITY OF ILLNESS IN THE CHILD
By Dr. Derek Louey
ASSESSING SEVERITY OF ILLNESS• Applies particularly to
neonates/infants/toddlers
• Don’t be intimidated
• Follow a systematic approach
• Assess severity first - diagnosis comes later
ASSESSING SEVERITY OF ILLNESS• Initial assessment
• Occurs without needing to touch the child• Can be performed rapidly in less than 1 minute• Done at triage
• Taking of vital signs
ASSESSING SEVERITY OF ILLNESS• Airway
• Breathing
• Circulation
• Disability (Neurological)
• ExposureLIFE-THREATENING ILLNESSES ACT BY EXERTING THEIR EFFECT ON THE ABOVE
AIRWAY
• Stridor
• Tracheal tug
• Drooling
BREATHING
• Increased work
• Increasing fatigue
• Decreased effectiveness
BREATHING
• Increased work• Recession RR• Grunting• Nasal flare• Accessory muscle
BREATHING
• Increasing fatigue RR breath sounds chest/abdominal movement• Apnoeic spells (c.f. periodic breathing)
BREATHING
• Decreasing effectiveness• Cyanosis Alertness
CIRCULATION
• Pallor/Peripheral cyanosis capillary refill
DISABILITY
• Conscious state
• Eye contact
• Activity
• Cry
DISABILITY
• Conscious state• Lethargic/Dull/Expressionless• Irritable• Not recognizing mother• Seizures• Not responding to pain• Quiet/Unresponsive
DISABILITY
• Eye contact/Smile• Lack of social smile• Not Fixing/Following/Focusing• Glassy stare
DISABILITY
• Activity• Require assistance• Not ambulating
DISABILITY
• Cry• Unable to be placated by mother• Whimpering/Sobbing• Irritable• Weak/Moaning/High pitched
EXPOSURE
• Mottled
• Petechiae
• Unexplained bruising (NAI)
VITAL SIGNS
• Different reference range for different ages
• BP is an important value often forgotten
• Hypothermia is suggestive of sepsis
• Pulse oximetry - ‘the fifth vital sign’
• Weigh the child
• Check blood sugar
WHY WEIGH THE CHILD?
• Changes of weight are a good guide to degree of dehydration
• Determines drug dosing
• Determines IV fluid calculations
SIGNS OF SEVERE ILLNESS
• Resting stridor
• Marked intercostal/sternal recession with accessory muscle use and tachypnea
• Cyanosis
• Capillary refill > 4sec (normal < 2 sec) / HR
• Impalpable pulse or hypotension or HR
• Not fixing/following or responding to environment
REASURRING SIGNS
• No stridor or only stridor with activity
• Mild recession
• Good colour
• Capillary refill < 2 sec
• Responding to mother and examiner/Able to be placated by mother
PRACTICAL TIPS
• Maintain a calm and reassuring manner (helps the parents and yourself)
• Keep a handy reference at triage of age-related ranges of paediatric vital signs
• When assessing capillary refill - choose an area of the trunk and apply pressure for 4 secs before releasing
PRACTICAL TIPS
• Assess pulse at brachial artery (inside elbow)
• Use age appropriate BP cuff (width 2/3 circumferance)
• Use paediatric probe for pulse oximetry
PRACTICAL TIPS
• Weighing the child• use proper paediatric scales (NOT adult scales)• ideally unclothed with small babies• Record to within 0.1kg for a neonate• Record to 0.5kg for an infant