ASSESSING SEVERITY OF ILLNESS IN THE CHILD

ASSESSING SEVERITY OF ILLNESS IN THE CHILD By Dr. Derek Louey

ASSESSING SEVERITY OF ILLNESS • Applies particularly to neonates/infants/toddlers • Don’t be intimidated • Follow a systematic approach • Assess severity first - diagnosis comes later

ASSESSING SEVERITY OF ILLNESS • Initial assessment • Occurs without needing to touch the child • Can be performed rapidly in less than 1 minute • Done at triage • Taking of vital signs

ASSESSING SEVERITY OF ILLNESS • Airway • Breathing • Circulation • Disability (Neurological) • Exposure LIFE-THREATENING ILLNESSES ACT BY EXERTING THEIR EFFECT ON THE ABOVE

AIRWAY • Stridor • Tracheal tug • Drooling

BREATHING • Increased work • Increasing fatigue • Decreased effectiveness

BREATHING • Increased work • Recession •  RR • Grunting • Nasal flare • Accessory muscle

BREATHING • Increasing fatigue •  RR •  breath sounds •  chest/abdominal movement • Apnoeic spells (c.f. periodic breathing)

BREATHING • Decreasing effectiveness • Cyanosis •  Alertness

CIRCULATION • Pallor/Peripheral cyanosis •  capillary refill

DISABILITY • Conscious state • Eye contact • Activity • Cry

DISABILITY • Conscious state • Lethargic/Dull/Expressionless • Irritable • Not recognizing mother • Seizures • Not responding to pain • Quiet/Unresponsive

DISABILITY • Eye contact/Smile • Lack of social smile • Not Fixing/Following/Focusing • Glassy stare

DISABILITY • Activity • Require assistance • Not ambulating

DISABILITY • Cry • Unable to be placated by mother • Whimpering/Sobbing • Irritable • Weak/Moaning/High pitched

EXPOSURE • Mottled • Petechiae • Unexplained bruising (NAI)

VITAL SIGNS • Different reference range for different ages • BP is an important value often forgotten • Hypothermia is suggestive of sepsis • Pulse oximetry - ‘the fifth vital sign’ • Weigh the child • Check blood sugar

WHY WEIGH THE CHILD? • Changes of weight are a good guide to degree of dehydration • Determines drug dosing • Determines IV fluid calculations

SIGNS OF SEVERE ILLNESS • Resting stridor • Marked intercostal/sternal recession with accessory muscle use and tachypnea • Cyanosis • Capillary refill > 4sec (normal < 2 sec) /  HR • Impalpable pulse or hypotension or  HR • Not fixing/following or responding to environment

REASURRING SIGNS • No stridor or only stridor with activity • Mild recession • Good colour • Capillary refill < 2 sec • Responding to mother and examiner/Able to be placated by mother

PRACTICAL TIPS • Maintain a calm and reassuring manner (helps the parents and yourself) • Keep a handy reference at triage of age-related ranges of paediatric vital signs • When assessing capillary refill - choose an area of the trunk and apply pressure for 4 secs before releasing

PRACTICAL TIPS • Assess pulse at brachial artery (inside elbow) • Use age appropriate BP cuff (width 2/3 circumferance) • Use paediatric probe for pulse oximetry

PRACTICAL TIPS • Weighing the child • use proper paediatric scales (NOT adult scales) • ideally unclothed with small babies • Record to within 0.1kg for a neonate • Record to 0.5kg for an infant

ASSESSING SEVERITY OF ILLNESS IN THE CHILD