Paediatric AssessmentA Structured Approach

Learning Outcomes

• Be able to recognise the unwell child

• To apply a systematic approach to assessing an unwell child utilising a primary survey

• To discuss the primary survey management of care for the unwell child

Primary SurveySystematic approach applying the Paediatric Assessment Triangle with Primary Survey

A irway

B reathing

C irculation

D isability

AirwayAssess vocalisations - crying or talking indicate ventilation and some degree of airway patency

Look for chest/ abdominal movement, symmetry and recessionListen for breathing sounds and stridorFeel for expired air

Reassess after using any airway opening manoeuvre

Management of AirwayThere are four steps in the management of the airway:1. OPEN the airway – Posture, chin lift/jaw thrust2. CLEAR the airway – Suction, finger sweep3. SECURE the airway – Airway adjuncts e.g. oro/nasopharyngeal airway, LMA and ETT4. MONITOR the airway

Breathing

Effort

Efficacy

Effect

Respiratory RatesAge Rate (breaths per min)

Infant 30 – 60

Toddler 24 - 40

Preschoolers 22 - 34

School aged child 18 - 30

Adolescent 12 - 16

Effort of Breathing

Respiratory rate

Accessory muscle use

Recession

Nasal flaring

Gasping

Child's position

Airway noises

Inspiratory stridor

Expiratory wheeze

Grunting

Image from - http://www.tracheostomy.com/care/complications/index.htm

Normal

Moderate

Severe

Effort of BreathingIncreased effort of breathing DOES NOT occur in three circumstances

1. Exhaustion (with imminent resp. arrest)

2. Central respiratory depression

3. Neuromuscular disease

Efficacy of BreathingLook for chest expansion, symmetry and abdominal excursion

Air entry / breath soundsListen in all areas – back, front and mid axillary line

Efficacy of BreathingPulse oximetry is acknowledged as a measure of efficacy

The measurement in air is the most useful, with SpO2 <95% considered abnormal, and <85% potentially life threatening. Normal SpO2 in oxygen does not rule out respiratory failure, with an elevated CO2

A silent chest is a pre-terminal sign

Effect - Adequacy of breathing• Heart rate - Tachycardia/ bradycardia

• SpO2 in room air - SpO2 of <85% is a pre-terminal sign

• Skin colour - Pallor, sweaty, mottling secondary to endogenous epinephrine

• Mental status - Agitation, restlessness, quiet, reduced conscious level, coma

Management of BreathingIs the breathing effective? – Administer O2therapy

If ineffective or apnoea• Airway opening manoeuvres• Support ventilation (adjuncts) or intubation

Reduce stressors• Parents present• Position of comfort

CirculationAs homeostatic mechanisms function particularly well in children, and compensation for inadequate circulatory function is good, a thorough circulation assessment is important

Remember, in a child, it can be difficult to detect circulatory failure until a late stage

CirculationCirculatory assessment should look at both circulatory status and the effects of inadequate circulation on other organs systems.

Heart Rate and BP are classical measures, but skin perfusion such as capillary refill, skin pallor, temperature or turgor can be more useful in detecting the early stages of compensated shock

CirculationHeart Rate

• Tachycardia – key sign of shock• Bradycardia – late sign

Systemic Perfusion• Peripheral pulses - pulse volume weak thready

or absent indicates shock• Skin perfusion - capillary refill, mottled, cool/

warm, turgor

CirculationSystemic Perfusion cont…• Mental status – agitation and altered conscious level

are important signs of circulatory inadequacy and the resultant cerebral hypoperfusion. Infants – irritable, floppy, failure to make eye contact with parents

Blood pressure• A child in shock may have a normal BP. Hypotension

is a late sign – indicates decompensation. • Use a correct sized BP cuff. • End organ perfusion = urinary output (1ml/kg/hr)

Management of CirculationVascular access (IV or IO)Bloods – BGL, U+E’s, FBC, CRP, Antibiotics,Blood cultures and coagulation studiesFluid bolus – Normal Saline 20ml/kg

+/- Glucose 2.5 ml/kg 10% dextroseECG Monitor - Treatment as per rhythm analysisChest compressions – HR < 60bpmDrugs as required i.e. for septic shock

DisabilityAssess and treat ABC firstABC problems may causes agitation, restlessness and depressed consciousness

Conscious levelPupilsPostureHistory of seizuresBlood glucose levels

Conscious levelQuick assessment

A Alert

V responds to Voice

P responds to Pain

U Unresponsive to all stimuli

Modified Glascow Coma Scale (GCS)

Eye OpeningIndicator of wakefulnessBrain stem arousal mechanisms

4 Spontaneous 3 Speech 2 Pain lower 1 None

Pupil size

Verbal ResponseRelate to development of child

Familiar wordsOrientated4 Confused3 Inappropriate2 Vocal sounds1 None

Under 4 yrs1 Words2 Vocal sound3 Cries1 None

Motor ResponseThe most sensitive/predictive measure

6 Obeys commands5 Localise to pain4 Withdrawal3 Abnormal flexion2 Extension1 None

Glascow Coma ScaleNOTE:A fall of 1 point in Motor Response (M) mandates action/review whereas for Verbal Response (V) and Eye Opening (E) a fall of 2 points mandate action/review

Example:

@ 1800 was E=4, V=5, M=6

@ 1900 now E=4, V=4, M=5 – Needs review

Adjuncts to Primary SurveyMonitoring

ECG, SpO2, respiration, blood pressure

ETCO2, blood gases, blood tests

Catheters

Indwelling catheter

Oro/nasogastric tube

Investigations

Handover and DocumentationName and ageMini history – if new Presentation – Primary Survey

Airway - AdjunctsBreathing – Oxygen/VentilationCirculation – IV/IO access and fluid bolusesDisability - AVPU/GCS

Actions/ therapy and outcomes – Secondary Survey

SummaryBe prepared for child’s arrival

Primary assessment – ABCD treat as find

Secondary assessment – looking for key features and treat

Final stage – stabilise and transferFor more information about Primary/Secondary Survey, see Learner Notes and Resources