The Unwell Child

Question 1

What is the paediatric assessment triangle (PAT) comprised of?

Answer 1

1. Appearance
2. WOB
3. Circulation to skin

Question 2

What should we assess for the appearance in PAT?

Answer 2

TICLS:

• tone
• Interactivity/mental status
• Consolability
• Look/gaze
• Speech/cry

Question 3

What are some signs of increased WOB in children?

Answer 3

• Body position: sniffing position, tripod position
• Visible chest/abdomen movements
• Breathing pattern and pace (tachypnoea)
• Abnormal sounds: snoring, hoarse speech, grunting, wheezing, gasping
• Nasal flaring
• Accessory muscle use (head bobbing in infants)/minimal chest wall movement
  • Sternal, supraclavicular, substernal, intercostal recession present

Question 4

After PAT, what should be done in the assessment of the unwell child?

Answer 4

Primary survey (ABCDE), then secondary survey

Question 5

How can we estimate the tube size required for an ETT?

Answer 5

• inner diameter (mm) = (age in years/4) + 3 (cuffed tubes) or + 4 (uncuffed tubes)
• Practical: diameter of patient’s little finger

Question 6

How can we calculate what the lower limit of an acceptable BP is for a child?

Answer 6

Lower limit of acceptable BP: minimal SBP = 70+ (2 x age in years)

Question 7

What is defined as bradycardia in children vs infants

Answer 7

<60 in children, <100 in newborns

Question 8

How can we establish access to administer fluids given poor circulation in an unwell child?

Answer 8

1. Venous access
   ○ Common sites: dorsum of hand/mood, medial ankle/forehead/scalp
2. Intra-osseous puncture
   ○ After 3 attempts to obtain venous access, or after 90-120s of trying, or if having active CPR
   ○ 1st line site: medial proximal tibia, 1-2cm below tibial tuberosity

Question 9

What scales can we use to assess disability in the primary survey of an unwell child?

Answer 9

2. AVPU (alert, response to verbal stimuli, response to pain, unresponsive) scale
3. Paediatric GCS

Question 10

What mnemonic can we use to guide the secondary survey of an unwell child?

Answer 10

SAMPLE:

• Signs/Sx
• Allergies
• Medications
• PMHx
• Last food/liquid
• Events

Question 11

What are some signs of normal CNS activity in an infant?

Answer 11

• Wake regularly for feeds
• Suck strongly on breast/bottle
• Rousable to activity (random movements of limbs, not stereotyped/lateralised)
• Normal sounding cry
• Have a flexed posture with some tone
  
  • Flexed to prevent heat loss, posture in womb

Question 12

Stridor vs wheeze: where is the airway obstruction?

Answer 12

• Stridor: upper

- Wheeze: lower

Question 13

What is an extremely important sign of abnormal respiration, that indicates serious illness in neonates?

Answer 13

Apnoea:

• normal neonates never have apnoea
• Bronchiolitis, sepsis, pertussis common causes of apnoea in early weeks

Question 14

What are some causes of tachypnoea to think about?

Answer 14

Systemic
• Fever
• Acidosis
• Anaemia

Resp
• Asthma
• Pneumonia
• Bronchiolitis

CV
• Cardiac Failure

Other
• Psychogenic
• CNS pathology

Question 15

What are some causes of tachycardia to think about?

Answer 15

Systemic	
• Fever
• Hypoxia
• Hypercarbia
• Anaemia

CV
• Hypovolaemia
• Arrhythmia
• Cardiac failure

Other	
• Pain
• Anxiety
• Drugs
• Seizures

Question 16

What is a very important cause of bradycardia you shouldn’t forget?

Answer 16

Hypoxia

Question 17

What are some causes of hypotension to think about?

Answer 17

• Pre-load
	○ Hypovolaemia
• Afterload
	○ Vasodilatation (sepsis, anaphylaxis)
	○ Drugs
	○ Pump failure(tachyarrhythmia, myocarditis, tamponade, CHD)

Question 18

What is important to remember about intubation in a severely hypovolaemic child?

Answer 18

*Don’t intubate if severe hypovolaemia because you need an anaesthetic, which is a negative inotrope and would reduce VC - always resusc first