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Recognition of a Sick Child

Recognition of a Sick Child. Aims of Assessment. LIFE THREATENING. Potentially Life Threatening. Not Life Threatening. Clinical Parameters. Interact!.

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Recognition of a Sick Child

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  1. Recognition of a Sick Child

  2. Aims of Assessment LIFE THREATENING Potentially Life Threatening Not Life Threatening

  3. Clinical Parameters Interact! • Whatever the cause and whichever the organ system involved, the clues to recognition of serious and deteriorating physiology can be found in just 3 clinical parameters • ABNORMAL BEHAVIOR • ABNORMAL RESPIRATION • ABNORMAL CIRCULATION

  4. In every Sick / Potentially Sick Child • ASK • Behavior, Feeding, Urine output • LOOK • Appearance, Breathing, Circulation, others • LISTEN • Speech, Cry, Breathing, MOTHER

  5. In every Sick / Potentially Sick Child • FEEL • Pulses, Warmth, Extremities • SMELL • MEASURE • HR, RR, BP, TEMP, • O2 Saturation, Blood Sugar

  6. Equipment for Assessment LOOK LISTEN FEEL MEASURE

  7. Question Interact! • What would be the three main things you would ask to rapidly assess a sick child?

  8. Step 1 - Ask BEHAVIOR FEEDING URINE OUTPUT

  9. Step 2 – Look…..Appearance • Behaviour • Look/Gaze - Not playful, Lethargic • Anxious – hypoxic • Interactivity • No / decreased Interactions with parents, surroundings • Consolability • Consolable, not consolable

  10. Step 2 – Look…..Appearance • Posture and Tone • Limp, stiff, curled up, neck retraction • Feeding • Feeding well, Not feeding • Pain facies • Is the infant/child in moderate to severe pain?

  11. Look…..Breathing Interact!

  12. What are other Respiratory LOOK Signs that are Important? • RATE: Fast or Slow • TYPE: Thoraco-abd, Abd or Thoracic • REGULARITY/RHYTHM • RETRACTIONS: Mild, Moderate or Severe

  13. Look…..Circulation • Diaphoresis: excessive sweating • Mottling of skin • Colour: cyanosis present/absent, peripheral/central

  14. Look…..Others • Bleeding • Fractures/ deformities • Rashes

  15. Listen Cry Respiratory Sounds Speech Mother’s concerns

  16. Stridor Interact!

  17. Wheeze Interact!

  18. Grunt Interact!

  19. Recognition of the Seriously Ill Child - Efficacy of Breathing Interact! • A silent chest is a pre-terminal sign

  20. Step 4 - Feel • PULSES: Peripheral and central • SKIN: Warmth, Turgor. Cold and sweaty palms and soles usually indicate poor perfusion • CFT • EXTREMITIES: injuries / fractures / hematomas

  21. How do you Assess Capillary Refill Time? Interact! • Where? • How long? • Position of limb? • Normal? • Physiological causes of prolonged CRT?

  22. CRT

  23. Step 5 – Smell, which Conditions would Help? Interact! • DKA • IEM • POISONINGS

  24. For warning signs Refer SOS-HOPE APP Step 6 – Measure Respiratory Rate, Heart Rate and Blood Pressure Warning Signs for Impending Acute Deterioration

  25. Measure • Temperature • Pulse Oximetry • Capillary Blood Glucose level

  26. For key values Refer SOS-HOPE APP Key Values in Practice • Pulse > 220/min consider SVT • Cap refill > 2 seconds is not normal • BP in kids > 1 year = 70 + (2 x age) • RR > 60/min NB, > 50/min till 1 yr, > 40 /min till 5 yrs • Pulse oximetry < 92% In room air

  27. For key values Refer SOS-HOPE APP Key Values in Practice • Blood Glucose • < 45mg/dl on day 1 of life newborn • < 50mg/dl after day 1 of life in newborn • Hypoglycemia in children - < 50mg/dl of whole blood glucose • Hypothermia is diagnosed by identification of a core body temperature that is <35°C (95°F) • Heat stroke is defined as a core temperature ≥40°C (104°F) accompanied by central nervous system dysfunction in patients with environmental heat exposure

  28. Ask Look Listen Feel Smell Measure We Have Done a Rapid Assessment - 6 Steps

  29. From the Assessment we need to TRIAGE What is the meaning of TRIAGE

  30. Triage Levels

  31. When Would You Call It Triage Level 1 BEHAVIOUR RESPIRATION CIRCULATION ASK LOOK LISTEN FEEL SMELL MEASURE

  32. What to do? Severe Impairment of 1 or More Parameters • Unresponsive or altered consciousness or lethargic • HR < > NR +/- 2 SD , RR < > NR +/- 2 SD (Grossly abnormal) • Inadequate breathing • Moderate to severe respiratory distress/ marked stridor • Shock: CFT > 4 secs, BP lower than normal for age • Cyanosis • THIS IS AN EMERGENCY: ACT FAST! STABILIZE

  33. When Would You Call It Triage Level 2 BEHAVIOUR RESPIRATION CIRCULATION ASK LOOK LISTEN FEEL SMELL MEASURE

  34. What to do? Mild-Moderate Impairment of 1 or More Parameters • Infant – unconsolable, not feeding, atypical behaviour • HR , RR outside NR for age • Mild-Moderate stridor • Mild distress • Capillary refill > 2 sec but < 4 sec • OBSERVE CLOSELY, TREAT, MAY DETERIORATE FAST!

  35. When Would You Call It Triage Level 3 BEHAVIOUR RESPIRATION CIRCULATION ASK LOOK LISTEN FEEL SMELL MEASURE

  36. What to do? Mild or No Impairment of any Parameter • No history of recent behavior/appearance change • HR & RR - normal for age/mildly deranged • CFT < 2 sec • BP in normal range for age • THIS IS NON URGENT

  37. Interact! There Are Always Exceptions in any Rule When would you triage a child more serious than he actually is?

  38. Beware !! • Sick infant, < 3 months of age • Temp > 40 deg C or hypothermia • Suspected ingestion of unknown substance or unknown quantity of known substance • Severe pain

  39. Beware !! • Any illness in a child with severe malnutrition • Burns: major - > 10% BSA &/or involving airway • Purpuric rashes, target lesions • Discordant Physical findings • MOTHER

  40. Case 1 Video • 11 months infant presents with • Fever 2 days • Cough 2 days, sleep disturbed, feeding well, passed urine twice in past 4 hours • O/E: Behavior alright, interactive • Breathing fast 46/min, mild retractions • HR = 118 / min, peripheral pulses are well felt, his CRT < 2 secs, BP is within Normal limits • Temp 39.2 deg C, Saturation 94% • RS bilat fair AE, rhonchi+ • CATEGORIZE

  41. Case 1 – Response • This child has got derangement of a mild nature of his breathing • Other parameters are within normal limits

  42. Case 2 • 2 yr old boy presents with • Fever & Cough x 4 days • Not feeding well, less active, decreased urine output • O/E: Behavior Lethargic, • Breathing fast 62/min, mod-severe retractions • HR = 136/min, peripheral pulses are fast, his CRT 4 secs, BP is within Normal limits • Temp 39.8 deg C, Saturation 88% • CATEGORIZE Video

  43. Case 2 - Response • This child is sicker than case # 1, he is hypoxemia, he also may have compensated shock • His categorization would be Urgent • Action ?

  44. Case 3 • A 3 yr boy brought with • Vomiting & watery loose stools for 3 days, inactive & no urination for past 24 hours • O/E: Behavior – drowsy, reacting only to painful stimuli • Breathing fast 56/min with intermittent sighing breathing • HR = 176/min, peripheral pulses are feeble, his CRT > 5 secs, BP is un-recordable, • Temp 35.6 deg, Saturation 82% • CATEGORIZE

  45. Case 3 - Response • Measure his blood sugar. Found to be 20mg/dl • This child is in decompensated shock, with probable acidosis, hypoxia, and hypothermia. He may be also in septic shock • His category would be Red

  46. In Every Sick/Potentially Sick Child • ASK • Behavior, feeding, urine output • LOOK • Appearance, Breathing, Circulation, Others • LISTEN • Speech, Cry, Breathing, MOTHER • FEEL • Pulses, Warmth, Extremities • SMELL • MEASURE • HR, RR, BP, TEMP, O2 SATN, Blood Sugar

  47. In Every Sick / Potentially Sick Child CATEGORIZE • Emergency needing Resuscitation • Potentially sick, can deteriorate fast • Non Urgent ACT • Stabilize & transfer • Stabilize & Observe closely • Treat and Follow up

  48. So it is very important to triage a sick child rapidly and either initiate stabilization or resuscitation depending on the severity

  49. Basic Principles: III Children • Regardless of the aetiology→ information required for assessment and management is the same for all children • Simple clinical tools are sufficient to recognize sick or potentially sick children • kids ‘can deteriorate quickly……so act in time’ Liverpool Primary Care Trust, Western Cheshire

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