Recognition of the critically ill child and clinical assessment

1
Recognition of the critically ill child and
clinical assessment

• P Ramnarayan, Consultant, CATS/ SMH
• Lynn Shields, ANP, CATS

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Children - just small adults?

• Size
• Airway
• Breathing
• Circulation
• Neurology
• Temperature control

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Size

• Birth wt 3.5 Kg
• 1yr 10 kg
• Formula
• Wt (Kg) 2 (age in yrs 4)
• Prescribing is weight based!

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Airway

• Short neck
• Small mouth
• Tongue large
• Floor of mouth compressible
• Nasal breathers

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Airway obstruction

• Stridor
• Croup
• Tracheitis
• Stertor
• Decreased conscious level
• (Flu encephalitis)
• Sleep apnoea

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Breathing

• Short ribs
• Compliant chest wall
• Greater resistance to breathing

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Breathing

• Respiratory rate
• lt1 yr 30-40 bpm
• 1-2yrs 25-35
• 2-5yrs 25-30
• 5-12yrs 20-25
• gt12yrs 15-20

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Respiratory failure

• BREATHING PROBLEM
• Asthma
• Bronchiolitis
• Pneumonia
• (Flu pneumonitis)
• Aspiration
• Pulmonary oedema

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Pneumonitis
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Respiratory failure

• SIGNS
• Increased resp rate
• Subcostal recession
• Intercostal recession
• GRUNTING IS BAD!

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Circulation

• Circulating blood volume 70-80mls/kg
• Absolute amounts of blood loss can be critically
  important!
• Body surface area very high
• Heat loss fluid loss in burns

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Circulation

• Heart rate
• lt1yr 110-160 bpm
• 1-2yrs 100-150
• 2-5yrs 95-140
• 5-12yrs 80-120
• gt12yrs 60-100

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Circulation

• Blood Pressure Normal Systolic
• lt1yr 70-90 mm Hg
• 1-2yrs 80-95
• 2-5yrs 80-100
• 5-12yrs 90-110
• gt12yrs 100-120

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Circulatory failure

• SHOCK
• Hypovolaemia (diarrhoea, trauma, burns)
• Septic
• (Flu associated secondary infection)
• Anaphylaxis
• Cardiac failure

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Circulatory failure

• SHOCK
• Tachycardia
• Cool peripheries (CRT)
• Weak pulses
• Poor urine output
• Confusion, drowsiness
• HYPOTENSION IS BAD!

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Neurology

• Cant talk!
• Uncooperative!
• Developmentally appropriate?

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A.V.P.U. Alert Responding to Voice Responding to
Pain Unresponsive
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Neurological failure

• RAISED INTRACRANIAL PRESSURE
• Meningitis
• Encephalitis
• Trauma head injury
• Hydrocephalus
• Intracranial tumour/bleed

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Neurology

• RAISED ICP
• Decreased conscious level
• Abnormal posture
• Vomiting
• Headache
• Pupillary changes
• BRADYCARDIA-HYPERTENSION IS BAD!

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Scenario

• 6 month old baby
• Ex prem 25 weeks
• Discharged from NNU 4 weeks ago
• Snuffly last few days
• Vomiting
• Fast breathing

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Scenario

• HR 180
• BP 70/30
• RR 80
• SpO2 87 in air, 99 in 10 l/min O2
• Temp 37.6 C
• Subcostal recession

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Scenario

• 16 month old boy
• Snuffly past 24 hours
• Poor feeding, unwell
• Irritable
• Crying constantly

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Scenario

• HR 180
• BP 90/70
• RR 60
• SpO2 94 in room air
• A V P U
• CRT 3sec

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Scenario

• 4 year old girl
• 2 day h/o being unwell
• Drowsy and less responsive
• Vomiting x 10 today
• Brought to AE

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Scenario

• HR 70
• SpO2 99 in air
• RR 30
• BP 130/80
• No chest retraction
• CFT 2 sec

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Questions?