Mod D Tech 25 Recognition and management of the sick child including SUDICA Flashcards
Anatomy and Physiology of infants and children
- Large tongue
- Large head, short neck
- Small face & mandible
- Narrow nostrils
- Loose teeth
- Delicate soft palate
- High horseshoe shaped epiglottis
Breathing
§Lungs are relatively immature in infancy
§Infants rely on diaphragmatic breathing
§Belly breathing normal in the infant
§Infants immature intercostal muscles therefore tire quickly
§Infants have very compliant walls, reducing ability to splint the chest
§Ribs do not fracture easily – possibility of serious underlying damage
Recognition of Potential
Respiratory Failure
Assess the severity of respiratory difficulty in 3 ways:
- Work / effort of breathing
- Effectiveness of breathing
- Effects of respiratory inadequacy on other organs
Work of Breathing
Signs of increased work:
- Respiratory rate (tachypnoea)
- Recession – intercostal, subcostal, sternal
- Inspiratory or expiratory noises
- Wheezing or grunting
- Use of accessory muscles
- Flaring of alae nasi
- Tracheal tug
Breathing – Assessment and Recognition of Potential
Respiratory Impairment
•Rate
•
Rapid breathing in a child at rest indicates that increased ventilation is due to either airway, lung or circulatory / metabolic problems
A falling respiratory rate in the presence of other parameters worsening is suggestive of exhaustion – this indicates imminent respiratory arrest
Normal Respiratory Rates

Abnormal Values
resp above 40 suggest what
•Resps > 40 breaths per minute suggests respiratory distress in all children except newborns
•
Remember (neonates) newborns normal respiratory rate is 40 – 60 bpm
Respiratory Noises
Inspiratory:
stridor
laryngeal / tracheal obstruction
croup, foreign body, epiglottitis
Expiratory:
wheeze
lower airway obstruction
Asthma
Cardiovascular Effects
- Tachycardia – occurs as a result of shock. In small children it may rise in excess of 200 bpm.
- Bradycardia – occurs as a result of hypoxia and acidosis and is a pre-terminal event
- Pulse volume – diminishes in shock
- •Capillary refill – measured on sternum or forehead
- •Blood Pressure – limited pre-hospital value
Normal Heart Rate

Abnormal Values
A weak, rapid pulse >130 beats per minute suggests
•A weak, rapid pulse >130 beats per minute suggests shock in all children but newborns (norm 120-180bpm)
•
BP = 80 + (age in years x 2)
Persistent tachycardia
is most reliable indicator of what in paeds
Persistent tachycardia
is most reliable indicator of shock.
Cardiovascular signs
Capillary refill
•A delay of more than two seconds in association with other signs of shock and in a warm child suggests poor peripheral perfusion

Effects of Circulatory Failure
on other Organs
- Skin Colour – poor tissue perfusion causes pallor
- Respiratory rate – acidosis will lead to tachypnoea
- Mental state – will be disturbed, classically with initial agitation followed by drowsiness
Pathophysiology of cardiac arrest in children
§Children usually have healthy hearts – unlike adults
§They do not stop easily!
§Commonest cause – hypoxia – acidosis
§Respiratory arrest usually precedes cardiac arrest in children
§The most common arrest rhythm - asystole
§ Initial management geared towards early oxygenation rather than defibrillation
Thermoregulation
§Relatively large surface area – cool quickly
§Small babies poorly developed thermoregulation
§May become hypothermic rather than develop a fever when ill
§Particularly important in trauma situations
Recognition of Potential Central Neurological Failure
Can be rapidly assessed by examination of:
- Conscious level – “AVPU”
- Posture – sick babies are often hypotonic, but meningitis may be stiff with arched back or neck. Decerebrate and decorticate rigidity are rare and have very serious significances
3Pupils – size, shape, reactivity
paeds Hypoglycaemia
§Children, particularly babies prone to hypoglycaemia when sick or injured
§
§Rapid exhaustion of glycogen stores
Decerebrate Rigidity
(Abnormal extension)

Decorticate Rigidity
(Abnormal Flexion)

Intra-abdominal organs
§Liver and spleen less well protected by the ribs, may well extend below the costal margin therefore more susceptible to injury
§
§Bladder higher rises higher out of the pelvis increasing the risk to trauma
SUDICA
A child death is one of the most emotionally traumatic and challenging events that an ambulance clinician will encounter
Resuscitation should always be attempted unless there is a condition unequivocally associated with death or a valid advance directive
Ensure that the family are aware where you are taking their infant/child… this should be the nearest appropriate emergency department, not direct to a mortuary
In unexpected deaths, when appropriate explain to the family that the death will be reported to the Coroner and that they will be interviewed by the Coroner’s Officer in due course
Paediatric Trauma
Causes of death in childhood
- SIDS (“Cot death”) – most common between 1 month and 1 year of age
- •Between the ages of 1 and 4 the cause is equally split between congenital abnormality and trauma
- •In the UK Trauma is the most frequent cause of death after 1 year of age
(Advanced Paediatric Life Support, ALSG)
Anatomical Considerations




