paediatric assessment a structured approach - amazon s3 · airway assess vocalisations - crying or...
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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