Approach to a sick

child
 Quick recognition

Immediate intervention
( Life saving)
Recognise Quickly
• Signs of:
• Respiratory distress/ respiratory failure
• Circulatory insufficiency
• Altered mentation
Chances of survival decrease by
17% for every minute’s delay in
initiation of CPR.
In EMERGENCY situation:
Approach should be-

• Structured
• Objective
• Systemic
Paediatric “CHAIN OF SURVIVAL”
1) Prevention of arrest
2) Early high quality bystander CPR
3) Rapid activation of Emergency Response System( ERS)
4) Effective Advanced Life Support( ALS)
5) Integrated post-cardiac arrest care
Revised guidelines(2015)
-American Heart Association(AHA)
-Indian Academy of Pediatrics (IAP)

Tier 1: Hands only CPR Tier 2: Compression and

breathing CPR
 Out-of hospital setting
Skilled BLS rescuer
 Lay rescuers( limited BLS skills)
30:2 compression- ventilation
Chest compressions only ratio
Tier 3: Multi-rescuer coordinated CPR
Compression
Ventilation
Defibrillation
 Team of multiple skilled rescuers.
Characteristics of high-quality CPR
• Start compression within 10 s of recognition of cardiac arrest.
• Push hard ( >1/3 anteroposterior diameter of chest)
• Push fast (100-120 compressions per minute)
• Allow complete chest recoil
• Minimize interruptions
• Avoid excessive ventilation
• Compression ventilation ratio ( single rescuer 30:2; multiple rescuer 15:2)
• If advanced airway is in place , one breath should be given every 6s with
continuous chest compressions.
Steps of BLS
1. Scene safety, assessment and circumstantial evidence
2. Activate ERS and get equipments
3. Breathing and pulse check
4. Determine next action
5. Begin high quality CPR
6. Attempt defibrillation with AED
7. Resume high- quality CPR
Pediatric Emergency Triage
Classification
• Level 1( Resuscitation)
• Level 2 ( Emergent)
• Level 3 ( Urgent)
• Level 4 ( Less Urgent)
• Level 5 ( Non- urgent)
Approach
• Evaluation
• Identification
• Intervention
Steps of Evaluation
• Initial assessment: PAT
• Primary assessment: ABCDE
• Secondary assessment: Sample history and focused examination
• Diagnostic tests
Evaluate
Clinical assessment Brief description
Primary assessment Rapid hands on ABCDE approach to
evaluate respiratory, cardiac and
neurological functions,
Includes assessment of vital signs &
pulse oximetry

Secondary assessment A focused medical history and a

focused physical exam

Diagnostic assessments Laboratory, radiological and other

advanced tests that helps the child’s
physiological condition and
diagnosis
Identify
Type and severity of potential problems:
TYPE SEVERITY

RESPIRATORY Upper airway obstruction Respiratory distress

Lower airway obstruction Respiratory failure
Lung tissue disease
Disordered control of
breathing

CIRCULATORY Hypovolemic shock Compensated shock

Distributive shock Hypotensive shock
Cardiogenic shock
Obstructive shock

CARDIOPULMONARY FAILURE
CARDIAC ARREST
Pediatric Assessment Triangle ( PAT)
• A- Appearance ( or
consciousnesses)
• B- Breathing
• C- Color
Appearance
• T- Tone
• I- Interactivity
• C- Consolability
• L- Look/ Gaze
• S- Speech / cry
Breathing
• Apnea/ Tachypnea/ Bradypnea
• Audible sounds
• Abnormal respiratory pattern
• Use of accessory muscles
Colour
• Pallor( anemia)
• Bruises, ecchymosis, petechial spots( bleeding diathesis)
• Mottling or dusky hue ( vasomotor instability)
• Cyanosis
PRIMARY ASSESSMENT
PRIMARY ASSESSMENT
• Hands on approach.
• Rapid cardiopulmonary and brain assessment.
• TARGET-identify severity and type of physiological insufficiency and follow E-I-I.
• 5 components-A: airway
B:breathing
C:circulation
D:disability
E:exposure
a.AIRWAY
EVALUATE IDENTIFY INTERVENE
• Look at the airway Open/clear No interventions needed
patency,secretions,vomitus
,FB,etc
• Listen for any noisy breathing Maintainable Positioning,suctioning,noninvasive
simpleairway adjuncts like
oropharyngeal airway or
nasopharyngeal airway
Nonmaintainable Requires invasive airway adjuncts
like tracheal tube or tracheostomy
tube
b. BREATHING
• Evaluate[ 5 components]
1. Respiratory rate(RR)
2. Work of breathing(WoB)
3. Chest wall movements and tidal volume.
4. Auscultation(Air entry and adventitious sounds)
5. Pulse oximetry
1. RESPIRATORY RATE
AGE R.R
Infant(1month-1yr) 30-53
Toddler(1-3yrs) 22-37
Preschooler(4-5yrs) 20-28
School age(6-12yrs) 18-25
Adolescent(13-18yrs) 12-20
Abnormal respiratory rates
• Tachypnea
 First sign of respiratory distress
 Always pathological when associated with increased WoB.
 Quiet tachypnea d/t fever , anxiety , cardiac , sepsis , metabolic , or
central causes(without use of any accessory muscles)
• BRADYPNEA
 More ominous than the fast breathing
 Any breathing rate less than 10 per min. at all ages is abnormal
: Respiratory muscle fatigue
: CNS injury or infection
: Hypothermia
: Respi. Depressant drugs and toxins
• APNEA
 Cessation of breathing for 20s or more/ earlier if associated with
cyanosis , bradycardia , pallor , hypotonia
 Central:CNS injury , drugs , infection.
 Obstuctive: FB , vocal cord paralysis , craniofacial anomalies , sleep
apnea
 Mixed
2. WORK OF BREATHING
GROUP OF MUSCLES INVOLVED RESPIRATORY TRACT LOCATION
Alae nasi , suprasternal, supraclavicular, Upper aiway
sternocleidomastoid
Subcostal, sternal Lower airway
Intercostal, grunting Lung parenchyma
Head bobbing and see-saw respirations mostly
indicate repiratory failure
3. CHEST WALL MOVEMENTS AND
TIDAL VOLUME
• Abnormal movements indicate
Underlying airway obstruction
Pulmonary , pleural or neuromuscular abnormalities
4. AUSCULTATION OF CHEST
ADVENTITIOUS SOUNDS ANATOMICAL LEVEL
Stridor Upper airway obstruction
Wheeze Lower airway obstruction
Crackles Lung parenchymal
disease(fluid/mucus /blood
Grunting Alveolar atelectasis
Asymmetric breath sounds Pleural
fluid/consolidation/pneumothorax
CLINICAL CORRELATE
Croup/foreign body
Asthma/foreign body
Pneumonia, pulmonary
hemorrhage/edema
Pneumonia,drowning
Foreign body, pleural effusion,
pneumothorax
5. PULSE OXIMETRY
• Normal SPaO2 is 94%or more in room air
• Indicates the oxygen saturation in the blood
• With oxygen support one should target 94-95%saturation
IDENTIFY
• SEVERITY
Respiratory distress-inc. WoB
Respiratory failure- resp. distress+(fatigue/deranged
consciousness/SPaO2 below 92%despite oxygen
supplemention/cyanosis
• TYPE
Upper airway obstruction
Lower airway obstruction
Lung parenchymal disease
Disordered control of breathing
c. CIRCULATION
 Signs of Shock (inability of circulation to meet the metabolic
demands of the body)picked up on clinical evaluation
• 5 components
1. Heart rate (HR)and rhythm
2. Central and peripheral pulses
3. Capillary filling time(CRT)
4. Skin color and temperature
5. Blood pressure(BP)measurement
1. HEART RATE AND RHYTHM
AGE Awake HR Sleeping HR
Infant (1month-1yr) 100-180 90-160
Toddler(1-3yrs) 98-140 80-120
Preschooler(4-5yrs) 80-120 65-100
School age(6-12yrs) 75-118 58-90
Adolescent(13-18 yrs) 60-100 50-90
HEART RATE CLINICAL CORRELATE
< 60bpm Bradycardia
>220 bpm in infant Tachyarrhythmia
>180bpm in a child Tachy arrhythmia
Upto 220 in infant Sinus tachycardia
Upto 180 in child Sinus tachycardia
2. CENTRAL AND PERIPHERAL
PULSES
• Central pulses
examine- femoral and axillary arteries (infants), carotid artery(
others)
• Peripheral pulses
examine-radial , temporal, posterior tibial

Low CO states= weak peripheral pulses f/b fall in bp f/b low volume
central pulsations
3. CAPILLARY REFILL TIME
• Evaluated under the nail bed or skin
• CRT in a normal individual- within 2 secs
• Increased CRT indicative of shock
 4. SKIN COLOR AND TEMPERATURE
• Normal pink color [ appreciable on skin over the face, ear lobes,
palms and soles, oral mucosa and conjunctival mucosa]
• Pale – low hb / poor circulation /N in individuals with thick skin
• Ashen gray/ mottled/cyanosed- ineffective circulation
• Distributive shock
5. BLOOD PRESSURE
• Hypotension BP below fifth centile for the age
• NB: urine output indirect indicator of kidney perfusion and circulatory
status of the child
AGE CUT OFF
1-12months <70 mm Hg

1-10yrs 70+(age in yrs*2)mm Hg

Above 10 yrs Atleast 90 mm Hg

IDENTIFY
• SEVERITY
Compensated or normotensive shock (lowCO but preserved BP)
Hypotensive shock(fails to maintain BP)
• BASED ON ETIOLOGY
Hypovemic shock
Distributive shock
Cardiogenic shock
Obstructive shock
d. DISABILITY
• Evaluates brain functions= cortical assessment +brainstem assessment
• Cortical assessment- Glasgow Coma Scale(GCS) or AVPU Scale(Alert,
Voice , Pain , Unresponsive)
• Brainstem assessment- pupillary reflex?
• NB: raised ICP leading to herniation-unequal pupil size ( urgent
intervention)
: bedside blood sugar testing and treat hypoglycemia
e. EXPOSURE
• Identify bleeds, injury, swelling distension , deformity and rashes
• Peripheral and core temperature measured
specific interventions for fever and hypothermia
IMMEDIATE INTERVENTIONS
EVALUATE IDENTIFY LIFE THREATENING
CONDITION
Airway Partial or complete airway
obstruction
Breathing No breathing/ineffective
breathing,asymmetric chest rise,
tension pneumothorax
Circulation Pulse feeble /not detected,
hypotension/blood loss
Disability Unresponsive, GCS <8,
hypoglycemia
Exposure Fever/hypothermia, bleeds
IMMEDIATE INTERVENTION
Heimlich’s maneuver, suction,
reposition of airway, naso or
oropharyngeal aiway
Oxygen,chest
compessions/ventilation,
needlethoracocentesis
CPR, fluid/blood bolus. Inotropes as
reqd.
If absent pulse start CPR. Elective
intubation, 10% dextrose bolus
Antipyretics/controlled warming,
pressure bandage/ surgical
intervention
PRIMARY ASSESSMENT
PRIMARY ASSESSMENT
• Hands on approach.
• Rapid cardiopulmonary and brain assessment.
• TARGET-identify severity and type of physiological insufficiency and follow E-I-I.
• 5 components-A: airway
B:breathing
C:circulation
D:disability
E:exposure
a.AIRWAY
EVALUATE IDENTIFY INTERVENE
• Look at the airway Open/clear No interventions needed
patency,secretions,vomitus
,FB,etc
• Listen for any noisy breathing Maintainable Positioning,suctioning,noninvasive
simpleairway adjuncts like
oropharyngeal airway or
nasopharyngeal airway
Nonmaintainable Requires invasive airway adjuncts
like tracheal tube or tracheostomy
tube
b. BREATHING
• Evaluate[ 5 components]
1. Respiratory rate(RR)
2. Work of breathing(WoB)
3. Chest wall movements and tidal volume.
4. Auscultation(Air entry and adventitious sounds)
5. Pulse oximetry
1. RESPIRATORY RATE
AGE R.R
Infant(1month-1yr) 30-53
Toddler(1-3yrs) 22-37
Preschooler(4-5yrs) 20-28
School age(6-12yrs) 18-25
Adolescent(13-18yrs) 12-20
Abnormal respiratory rates
• Tachypnea
 First sign of respiratory distress
 Always pathological when associated with increased WoB.
 Quiet tachypnea d/t fever , anxiety , cardiac , sepsis , metabolic , or
central causes(without use of any accessory muscles)
• BRADYPNEA
 More ominous than the fast breathing
 Any breathing rate less than 10 per min. at all ages is abnormal
: Respiratory muscle fatigue
: CNS injury or infection
: Hypothermia
: Respi. Depressant drugs and toxins
• APNEA
 Cessation of breathing for 20s or more/ earlier if associated with
cyanosis , bradycardia , pallor , hypotonia
 Central:CNS injury , drugs , infection.
 Obstuctive: FB , vocal cord paralysis , craniofacial anomalies , sleep
apnea
 Mixed
2. WORK OF BREATHING
GROUP OF MUSCLES INVOLVED RESPIRATORY TRACT LOCATION
Alae nasi , suprasternal, supraclavicular, Upper aiway
sternocleidomastoid
Subcostal, sternal Lower airway
Intercostal, grunting Lung parenchyma
Head bobbing and see-saw respirations mostly
indicate repiratory failure
3. CHEST WALL MOVEMENTS AND
TIDAL VOLUME
• Abnormal movements indicate
Underlying airway obstruction
Pulmonary , pleural or neuromuscular abnormalities
4. AUSCULTATION OF CHEST
ADVENTITIOUS SOUNDS ANATOMICAL LEVEL
Stridor Upper airway obstruction
Wheeze Lower airway obstruction
Crackles Lung parenchymal
disease(fluid/mucus /blood
Grunting Alveolar atelectasis
Asymmetric breath sounds Pleural
fluid/consolidation/pneumothorax
CLINICAL CORRELATE
Croup/foreign body
Asthma/foreign body
Pneumonia, pulmonary
hemorrhage/edema
Pneumonia,drowning
Foreign body, pleural effusion,
pneumothorax
5. PULSE OXIMETRY
• Normal SPaO2 is 94%or more in room air
• Indicates the oxygen saturation in the blood
• With oxygen support one should target 94-95%saturation
IDENTIFY
• SEVERITY
Respiratory distress-inc. WoB
Respiratory failure- resp. distress+(fatigue/deranged
consciousness/SPaO2 below 92%despite oxygen
supplemention/cyanosis
• TYPE
Upper airway obstruction
Lower airway obstruction
Lung parenchymal disease
Disordered control of breathing
c. CIRCULATION
 Signs of Shock (inability of circulation to meet the metabolic
demands of the body)picked up on clinical evaluation
• 5 components
1. Heart rate (HR)and rhythm
2. Central and peripheral pulses
3. Capillary filling time(CRT)
4. Skin color and temperature
5. Blood pressure(BP)measurement
1. HEART RATE AND RHYTHM
AGE Awake HR Sleeping HR
Infant (1month-1yr) 100-180 90-160
Toddler(1-3yrs) 98-140 80-120
Preschooler(4-5yrs) 80-120 65-100
School age(6-12yrs) 75-118 58-90
Adolescent(13-18 yrs) 60-100 50-90
HEART RATE CLINICAL CORRELATE
< 60bpm Bradycardia
>220 bpm in infant Tachyarrhythmia
>180bpm in a child Tachyarrhythmia
Upto 220 in infant Sinus tachycardia
Upto 180 in child Sinus tachycardia
2. CENTRAL AND PERIPHERAL
PULSES
• Central pulses
examine- femoral and axillary arteries (infants), carotid artery(
others)
• Peripheral pulses
examine-radial , temporal, posterior tibial

Low CO states= weak peripheral pulses f/b fall in bp f/b low volume
central pulsations
3. CAPILLARY REFILL TIME
• Evaluated under the nail bed or skin
• CRT in a normal individual- within 2 secs
• Increased CRT indicative of shock
 4. SKIN COLOR AND TEMPERATURE
• Normal pink color [ appreciable on skin over the face, ear lobes,
palms and soles, oral mucosa and conjunctival mucosa]
• Pale – low hb / poor circulation /N in individuals with thick skin
• Ashen gray/ mottled/cyanosed- ineffective circulation
• Distributive shock
5. BLOOD PRESSURE
• Hypotension BP below fifth centile for the age
• NB: urine output indirect indicator of kidney perfusion and circulatory
status of the child
AGE CUT OFF
1-12months <70 mm Hg

1-10yrs 70+(age in yrs*2)mm Hg

Above 10 yrs Atleast 90 mm Hg

IDENTIFY
• SEVERITY
Compensated or normotensive shock (lowCO but preserved BP)
Hypotensive shock(fails to maintain BP)
• BASED ON ETIOLOGY
Hypovemic shock
Distributive shock
Cardiogenic shock
Obstructive shock
d. DISABILITY
• Evaluates brain functions= cortical assessment +brainstem assessment
• Cortical assessment- Glasgow Coma Scale(GCS) or AVPU Scale(Alert,
Voice , Pain , Unresponsive)
• Brainstem assessment- pupillary light reflex
• NB: raised ICP leading to herniation-unequal pupil size ( urgent
intervention)
: bedside blood sugar testing and treat hypoglycemia
• GCS :
• Mild head injury GCS 13-15
• Moderate head injury GCS 9-12
• Severe head injury GCS 3-8
e. EXPOSURE
• Identify bleeds, injury, swelling distension , deformity and rashes
• Peripheral and core temperature measured
specific interventions for fever and hypothermia
IMMEDIATE INTERVENTIONS
EVALUATE IDENTIFY LIFE THREATENING
CONDITION
Airway Partial or complete airway
obstruction
Breathing No breathing/ineffective
breathing,asymmetric chest rise,
tension pneumothorax
Circulation Pulse feeble /not detected,
hypotension/blood loss
Disability Unresponsive, GCS <8,
hypoglycemia
Exposure Fever/hypothermia, bleeds
IMMEDIATE INTERVENTION
Heimlich’s maneuver, suction,
reposition of airway, naso or
oropharyngeal aiway
Oxygen,chest
compessions/ventilation,
needlethoracocentesis
CPR, fluid/blood bolus. Inotropes as
reqd.
If absent pulse start CPR. Elective
intubation, 10% dextrose bolus
Antipyretics/controlled warming,
pressure bandage/ surgical
intervention
 Secondary assessment
• After the initial Evaluation,Identification ,and
Interventions to stabilize the chid more information is
gathered from
• Focussed history
• Focussed physical exam
• Ongoing reassessment
 Focussed history
• Focused history has six components parameters which
together can be remembered as mnemonic ''SAMPLE''.

• S -signs & symptoms(Symptoms are important but they

are subjective)
• A - allergies
• M- medication
• P - past medical history
• L - last meal/last oral intake
• E- events leading to present illness/injury
 Focussed physical exam
• The physical examination Focuses on areas that have not been
covered in the primary assesment.these would bethe neck,lymph
nodes throat,neck stiffnes,and cardiac evaluations including the
murmurs and examination
• Severity of the child’s illness or injury should determine the extent
of the physical exam
Ongoing reassessment
• Essential to evaluate the response to treatment and to track the
progression of identified physiological and anatomical problems
• Elements :
• PAT
• ABCDE with vital signs & SpO2
• Assessment of abnormal anatomic and physiologic findings
• Review of the effectiveness of treatment interventions
Diagnostic assessment
• Helps detect and identify the presence and severity of respiratory and circulatory
problems.
• ABG/VBG/CBG
• Hb
• Central venous O2 sats
• Arterial lactate
• CVP
• IBP monitoring
• CXR/ECG/ECHO
• PEFR