Recognition of Sick Child Flashcards
(37 cards)
3 minute toolkit for sick children
A – Airway – Is it obstructed?
eg secretions, foreign body, stridor
B – Breathing – Is the child struggling to breathe?
Assess respiratory rate, look for recession/accessory muscle use, check oxygen saturation, auscultate the chest
C – Circulation – Is there evidence of poor circulation?
Assess colour skin, heart rate, capillary refill time (on sternum and fingers/toes), blood pressure, warm or cold hands/feet?
D – Disability – What is the child’s neurological state?
Assess pupil response to light, limb tone and movement, AVPU score/GCS
E – Exposure – Have you exposed the child and examined top-to-toe?
Rashes – viral rash, infectious disease rash, non-blanching rash (septicaemia?)
Any evidence of injury/trauma
Bruises – Always think Non-accidental injury in the non-mobile child
Use any safeguarding skills you have learnt on accredited courses in child protection to identify any marks on the skin, or how a child is kept, or their interaction with the parent(s)/guardian(s).
ENT – Ears, Nose and Throat
T – Temperature – Use a tympanic or axillary thermometer.
You may require a rectal thermometer in the very unwell child
T – Tummy – Is this soft? Distended? Tender? What are the bowel sounds like? Any masses? Any hernias?
In boys, never forget to examine the testis (testicular torsion = surgical emergency)
Urinalysis
D E F G – Don’t Ever Forget Glucose!
How to conduct examination
-Tummy: RR when settled, listen for airway noises and recession of chest wall. Listen to chest and HS, keep sitting on lap and check temp of hands and peripheral and central CRT
-Turn child around to listen to back of chest
-Feel abdomen on lap
-Pulse oximeter for sats and HR, BP?
-ENT last, tympanic thermometer, BM is very unwell
Airway Assessment
Check for secretions (eg Bronchiolitis)
If you hear stridor – think foreign body or croup
Do not examine the throat if you hear stridor. There is risk that you could cause deterioration to the child’s condition. Wait for senior help
Airway opening manoeuvres – Neutral in infant, head tilt – chin lift in a child, jaw thrust if not protecting own airway
Airway adjuncts – oro/naso pharyngeal airway (this will also check if gag reflex present in a child with reduced consciousness; if coughing they are protecting airway)
Breathing
Respiratory Rate – count over 30 seconds then multiply by two = respiratory rate/minute
=Different respiratory rates for different ages (RR: 30-40 neonate, 1-2 25-35, 2-3 25-30, 5-6 20-25, 12-13 15-20)
=DKA, septicaemia
Oxygen saturations using pulse oximeter
=This is dependent on a good trace on the monitor. May be falsely low if placed on cold extremities. Can appear well when decompensating, eyes do not pick up cyanosis until 85% or less. Normal 96, levels below 94% significant
Auscultation – once child is settled using distraction techniques
=A silent chest is a medical emergency (child may look well but not shifting air through the lungs on auscultation)
=Warm stethoscope first
=Wheeze, bronchial breathing, crepitations
Circulation
-Colour – pale (what is normal colour), blue, mottled (unusual: poor perfusion). This may be normal for the child, so check with parents
-Heart Rate – count over 30 seconds then multiply by two = Heart rate/minute
=Different heart rates for different ages (110-160 neonate, 1-2 100-150, 2-3 95-140, 5-6 80-120, 12-13 60-100)
=Note volume of pulse (weak/strong?)
=Infant (under 6 months) – check femoral and/or brachial pulses
=Child – check radial pulse
-Capillary Refill Time (CRT) – not to be used on its own when assessing circulation!
=Press firmly for 5 seconds on sternum (central) or fingers/toes (peripheral) and count refill time. Prolonged is over 2 seconds, suggesting poor circulation
-Temperature of hands/feet – warm or cold to touch?
-Blood pressure – consider using if the child is drowsy. Can give false results if the child is upset, BP maintained until shock
=Different blood pressures for different ages
=Use correct size cuff – 2/3 of the length of the upper arm
Disability
-Pupil assessment to light
=Sluggish = drug overdose? post seizure?
=Changing sizes = ongoing seizures?
=Asymmetrical = space occupying lesion? including haemorrhage ?
=Abnormal gaze post seizure
-Limb and tone - increased/decreased? difference between left and right of body? = CT Brain scan. Space occupying lesion?
-AVPU –Alert? or responding to Voice? or Pain? or is the child Unresponsive
=The more detailed “GCS” (Glasgow coma scale is covered in the Head Injury resource pack)
=True irritability (inconsolable infant) = Think Meningitis/raised intracranial pressure
=An increased temperature may not reflect if the child is truly drowsy
ENT Assessment
Ask the parents to firmly hold the infant/child
Normal ear drum is grey. Increased temperature can cause a pink ear drum which is not necessarily an infection.
Tonsils can be more pink with high temperature alone and not due to tonsillitis
Be aware that children often have large tonsils. This is can be a normal phenomenon.
Temperature
Use a tympanic thermometer
Axillary temperature is recommended in infants <4 weeks
Tummy
Examine lying flat
Use distracting techniques to keep the child calm
Do not forget the groin (hernias) and testes in boys (red, swollen and tender = surgical emergency)
Blood glucose
Not necessary to measure if alert and orientated
Do check if abdominal pain +/- headache = diabetes or early diabetic ketoacidosis
Communication and distraction techniques
-Child friendly
-Welcoming
-Providing toys/books/DVDs etc
-Use play therapists
-Always include the parents
-Adapt yourself to make the child comfortable and not distressed
Causes of paed fever
-Mild viral infection
-Serious bacterial infection (more likely under 2, most severe under 3 months)
=Meningitis, otitis media, tonsillitis, croup, pneumonia, surgical, septic arthritis, osteomyelitis, UTI
-Influenza
-Juvenile Onset arthritis, Kawasaki disease
Differentiating between minor and major infections
-Serious: cough in pneumonia, headache in meningitis, however usually vague
-A to E
-High RR, HR, peripheral shutdown
-Colour, behaviour, physiology, those under 2 most risk
-Parent worsening advice (written); feeding, drowsiness, fever persisting more than 5 days
Green- low risk in feverish illness
-Normal colour
-Responds normally to social cues
-Content/smiles
-Stays awake or awakens quickly
-Strong normal cry/ not crying
-Normal skin and eyes
-Moist mucous membranes
Amber/ intermediate risk in feverish illness
-Pallor reported by parent/carer
-Not responding normally to social cues
-No smile
-Wakes only with prolonged stimulation
-Decreased activity
-Nasal flaring
-Tachypnoea (>50 6-12 months, >40 >12 months)
-Oxygen stats <95%
-Crackles in chest
-Tachycardia (>160 <12 months, >150 12-24m, >140 2-5yrs)
-CRT >3
-Dry mucous membranes
-Poor feeding in infants
-Reduced UO
-Age 3-6 months Temp >39
-Fever for >5 days
-Rigors
-Swelling
-Non-weight bearing limb
Red/high risk in feverish illness
-Pale/mottled/ashen/blue
-No response to social cues
-Appears ill to a healthcare professional
-Does not wake or roused does not stay awake
-Weak, high-pitched or continuous cry
-Grunting
-Tachypnoea: resp rate >60
-Mod/severe chest indrawing
-Reduced skin turgor
-Aged <3 months temp >38
-Non-blanching rash
-Bulging fontanelle
-Neck stiffness
-Status epilepticus
-Focal neurological signs
-Focal seizures
Localised infection vs septicaemia
-Meningococcal septicaemia: purple rash
-Leaky blood vessels, poor contraction of heart, organ failure, septic shock
-Fluid replacement to restore circulation
-Check CRT (peripheral shutdown), venous blood gas (lactate, WCC, metabolic acidosis, base excess more than -3)
History of fever
-Listen to the parents – they are trying to tell you the diagnosis
=Behaviour (and after antipyretic, worrying if still drowsy) and colour
=Temperature (39.5, 38 in less than 3 months)
=Duration (>5 days; UTI, Kawasaki disease)
-The risk of serious infection is greatest in younger children, symptoms more vague
-Ask about other conditions that might make infection more likely (septicaemia more vague than localised, cerebral palsy, steroids, leukaemia, prematurity)
-Ask about immunisations and recent travel
Examination in fever
-Assess if the child is “unwell”
-Check the child’s colour and responsiveness
-Fever: height of fever poor predictor of serious infection, give antipyretics to relieve distress not for fever (recheck behaviour and physiology)
-Check the heart rate, respiratory rate and capillary refill time. (Degree of fever= 10 H, tachypnoea in septicaemia)
-BM stick (hypo in sepsis)
-Check all over for rash
-Bulging fontanelle, photophobia: meningitis
-Dull, non reflective, different to other drum, fluid: otitis media
-Large with exudate: tonsillitis
-Urine sample
-LP if under 1 year old or meningitis is suspected
Causes of rashes
-Infection
-Allergies
-Reactions to medications
-Stings and insect bites
-Chemical irritants (garden plants, nappy rash)
-Signs of systemic disease
Rash history
-Is the child well or ill?
-Is there an obvious cause of the rash?
-Listen to the parents – they are trying to tell you the diagnosis
=Contact with infectious child
=Eczema
=Fever, irritable, lethargic, easting and drinking, any other symptoms
=Cough and sore eyes measles
=Abdo pain in HSP
=Recent burn TTS
=Bleeding gums and lethargy: leukaemia
Examination of rash
-General assessment
-Erythema: mild viral, erythema toxicum neonatorum (Transient rash in babies under 1 week old and tends to have raised blotchy areas)
-Macular and papular: splotchy, no feel for macular, raised for papular. Mild viral, rubella, measles, Kawasaki disease
-Vesicular and pustular: chickenpox, HSV, shingles, staph. Vesicles viral, pustular bacterial
-Petechiae: pin prick flat
-Purpura: more than 2mm, blood has leaked from vessels, suggestive meningococcal disease
-Consider non-accidental injury in unexplained bruising
-Urticaria and eczema: allergy vs genetic. Seborrhoeic dermatitis cradle cap
Rash Red flags
-Meningococcal sepsis
-Stevens-Johnson Syndrome
-Toxic shock syndrome
-Kawasaki disease
-Henoch Schönlein purpura
-Anaphylaxis
-Idiopathic Thrombocytopenic purpura
-Leukaemia
Overview of meningococcal sepsis
-Neisseria meningiditis, most common in children under 5
-Non-blanching rash
-an ill-looking child
- non-blanching lesions larger than 2 mm in diameter (purpura) or non-specific
- a capillary refill time of 3 seconds or longer
- neck stiffness
