APPROACH TO UNSTABLE

PEDIATRICS PATIENTS IN
EMERGENCY DEPARTMENT
DR.DIGVIJAY VIKAS SURYAWANSHI MODERATOR:DTR.D.J. LALNEIRUOL
JUNIOR RESIDENT 2 ASSISTANT PROFESSOR
DEPT OF EMERGENCY MEDICINE DEPT OF EMERGENCY MEDICINE
• Introduction

• The seriously unwell child presents a daunting case, even for the most
experienced of clinicians.

• However, the adoption of a calm and structured approach to assessment

and management of the patient, enables the clinician to identify and treat
life threatening problems in a methodical manner.
Approach to Assessment
• Most of your assessment occurs before you ever touch a patient. This
is commonly known as the general impression or
Pediatric Assessment Triangle (PAT). PAT includes assessment of a
child’s appearance, work of breathing and circulation to skin.
PAT: Appearance
To help assess the child’s appearance, use the mnemonic TICLS (“Tickles”). TICLS stands for Tone,
Interactiveness, Consolability, Look/gaze and Speech/cry.

• Tone – Does the child move spontaneously? Resist examination? Sit or stand as age appropriate?
• Interactiveness – Is the child alert and engaged with their parent or the clinician? Do they interact
well with people or the environment? Do they reach for objects?
• Consolability – Does the child stop crying when the parent holds or comforts them? Do they have
a different response to their guardian versus the examining clinician?
• Look/gaze – Does the child make eye contact with the clinician? Do they visually track?
• Speech/cry – Does the child use speech that is developmentally appropriate?
PAT: Work of Breathing
Due to immature muscle mass, children’s bellies go in and out when they breathe, making it easy to
count respiratory rate. When infants and young toddlers must work to breathe, you may note
retractions, nasal flaring and/or abnormal positioning (e.g., tripod). Note any of these assessment
findings and quickly communicate them to the physician.

PAT: Circulation to Skin

• Observe the child’s interaction with the caregiver for alertness and look at their skin color. Is it an
appropriate color for the child’s ethnicity? Or do you note pallor, cyanosis, ashenness or mottling?
If you see any changes of concern, assess further and notify the physician.
• The outcome for children following cardiac arrest, is in general, poor and
therefore the emphasis in on early recognition of the signs of potential respiratory,
circulatory or central neurological failure, to help prevent the downward spiral to an
arrest situation.

• A key point to note is that in a healthcare environment you are rarely alone – always ask early for
help in these situations
The structured approach to the seriously ill child can be
divided into the following sections:

1.Primary ABCDE assessment and resuscitation

2.Secondary assessment and emergency treatment
3.Stabilisation and transfer
Primary ABCDE assessment and resuscitation
• The initial rapid assessment of a child should take less
than a minute. The aim of this is to identify life
threatening problems to guide resuscitation. It should take
less than a minute.
In an in-hospital setting, adjuncts such as naso-pharyngeal airways and
Guedel airways may also be appropriate. In a conscious child, stridor or hoarse
voice may indicate a compromised airway
Breathing assessment
• During this examination, you should make an assessment
of the effort, the efficacy and the effect of breathing:
Other signs of respiratory distress include grunting, flaring of the nostrils,
tracheal tug and accessory muscle use (intercostal, subcostal or at the
most severe sternal recession).
Gasping is a late sign of severe hypoxia.

In some children, despite hypoxia there will be no signs of increased

respiratory effort – these are:
1.Those who have had severe respiratory problems for some time and
have become fatigued. Exhaustion (seen in life threatening asthma) is a
pre terminal sign
2.Neuromuscular disease – such as muscular dystrophy
3.Central respiratory depression (from raised intracranial pressure,
poisoning or encephalopathy)
• Efficacy: ‘What are they achieving in terms of air movement
and gas exchange?’

• Observation of chest expansion and auscultation for air entry in

combination with oxygen saturations are important here.
• You may identify the asymmetrical air entry and bronchial breath
sounds of a pneumonia
• the wheeze and reduced air entry of acute asthma.

• Note a silent chest is an extremely worrying sign.

• Effect: ‘What is the effect of respiratory inadequacy
on the rest of the body?’

• Hypoxia will initially lead to tachycardia, however if it is prolonged or

severe this will lead to bradycardia, which is a pre terminal sign. Likewise,
cyanosis is visible with saturations below 70% and again is a late and pre terminal
sign.

• Hypoxia or hypercapnia will lead to agitation or drowsiness, which may present as

the child who will not cooperate with examination and seems very distressed or
alternatively, unusually quiet and withdrawn.
All children with respiratory difficulty or hypoxia should be given high
flow oxygen (15litres/min) through an oxygen mask with a
reservoir bag. If there is also inadequate respiratory effort,
then use a bag-valve mask and consider intubation and ventilation
as appropriate.

• In a choking patient who is conscious and seems to be coughing

effectively, encouraging coughing is often all the intervention
required. If the cough has become ineffective, 5 back blows
followed by 5 chest thrusts in a baby/abdominal thrusts in a child
are used to attempt to dislodge the foreign body. If they lose
consciousness, the life support algorithm is followed.
Circulation assessment

Record the patient’s heart rate, pulse volume, capillary refill time
and blood pressure. Children are very good at compensating
for alterations in their physiology and as such hypotension
is a late sign.
Assess the effect of any circulatory inadequacy on other organs.
These may include
• a raised respiratory rate (driven by the resultant metabolic
acidosis),
• reduced urine output,
• mottled skin with pale, cool peripheries (due to poor skin
perfusion)
• altered mental state.
Resuscitation
• If there are signs of circulatory compromise, establish venous or
intraosseous access rapidly and give a 20ml/kg bolus of 0.9%
sodium chloride.
• Further boluses should be guided by reassessment and inotropic
support considered if more than two boluses are needed.
• Note in DKA, the initial bolus is 10ml/kg due to the risk of cerebral
oedema.
• Venous access in seriously ill children is often difficult and fluid
bolus administration should not be delayed by repeated attempts at
cannulation – intraosseous access is rapid and effective and
should be considered early.
Resuscitation
• Consider intubation to stabilise the airway in any child with
a conscious level graded as P or U.
• Treat hypoglycaemia with a bolus of 2ml/kg 10% glucose IV
or IO, followed by a glucose infusion to prevent recurrence.
• In cases of suspected raised intracranial pressure consider
mannitol and neuroprotective measures
Exposure assessment

• A swift head to toe examination of the child may provide clues

as to the aetiology of the illness, for example a purpuric rash may
only be noted on full exposure or surgical scars may prompt you to
consider particular histories.

• Be careful to ensure exposed areas are recovered to help maintain

temperature control and preserve the child’s dignity.
Secondary assessment and emergency treatment:
Once immediately life threatening problems have been
addressed, move on to assess the patient in further detail.
This includes:

• Reassessing the response to initial resuscitative measures

• Taking a focused history
• Performing detailed systems based
examinations where appropriate
• Further investigations – these may include laboratory
blood tests, ECG, radiographs or other imaging such as CT
Below, some specific conditions and their emergency
treatment are discussed in further detail.
• Airway and Breathing
Circulation

Congenital heart disease

• This is one of the most common types of birth defect. Although many
of those affected are now identified by antenatal scanning or during
the newborn baby check, some first present to the ED within a few
days of life. This is because at this time the heart is still undergoing
changes, converting from the foetal to neonatal circulation.
One of the major structural changes is the closure of the ductus
arteriosus, a connection between the pulmonary artery and the
descending aorta. This reveals those who are dependent upon this duct to
enable mixing of blood to maintain their systemic or pulmonary
circulations.
Presentation of duct dependent lesions can vary widely
symptoms of poor feeding,
sleepiness and slightly fast breathing when the duct is starting to close,
to the collapsed baby in cardiogenic shock where closure is imminent.

This can often be a diagnostic challenge, since the decompensated patient

with sepsis or an inborn error or metabolism can have a very similar
presentation.
• If a duct dependent lesion is suspected, IV dinoprostone should be
administered – this helps to keep the duct open, therefore allowing
common mixing to occur until a definitive diagnosis and treatment by a
cardiologist can be sought.
Supraventricular Tachycardia (SVT)

• Supraventricular tachycardia (SVT) is the most common

arrhythmia seen in children. Older children with SVT typically
present with episodes of palpitations, chest pain and dizziness.
• Babies may present in extremis with signs of heart failure, following
prolonged episodes of SVT which have not been detected.
• If SVT is identified on a 12 lead ECG, further treatment involves a
trial of vagal manoeuvres followed by a rapid bolus of IV
adenosine or synchronous DC shock, depending upon the clinical
status of the child.
Disability (neurological)
Seizures
Seizures are common – 1 in 20 people experiencing one in their lifetime. Most often
they are brief (less than 5 minutes) and witnessed by parents, the child presenting
to the ED in a stable condition. However, sometimes seizures are prolonged and
ongoing at time of ED arrival requiring urgent intervention. If seizure activity is
ongoing at 20 minutes or there are shorter seizures with incomplete recovery
between, this is defined as status epilepticus.
Exposure
Sepsis
Sepsis is one of the commonest causes of serious illness in children and
should always be considered in a child who is either inexplicably unwell or
who remains unwell despite maximal therapy for another condition. Fever
is not always present and particularly in babies, hypothermia may occur.
• Ideally, cultures of blood, urine and CSF (in young babies or those with
signs of intracranial infection,) should be obtained prior to administering
antibiotics. However, if sampling proves problematic or the patient is too
clinically unstable then antibiotics should be given as soon as
possible. Each hospital will have their own guidelines for antibiotic
choices.
Stabilisation and transfer
Regular reassessment is essential in the ongoing care of
any unwell child. All patients should have the following
monitored:
• Oxygen saturations (plus CO2 monitoring if intubated)
• Pulse rate and rhythm
• Blood pressure
• Urine output
• Core temperature
• THANK YOU….