Seriously Ill Child

What is triage in paediatric emergencies, and how are PEWS used to detect deterioration?

Triage is the process of deciding how urgently a child needs assessment and treatment based on illness severity rather than order of arrival.
It may begin from first contact with healthcare services, including telephone, online, primary care, ambulance, or emergency department assessment.

In hospital, Paediatric Early Warning Scores (PEWS) help detect deterioration by assigning scores to abnormalities in heart rate, respiratory rate, consciousness level, oxygen saturation, temperature, and blood pressure; higher total scores trigger reassessment and escalation of care.

What are the normal vital signs by age group listed in the lecture for heart rate, respiratory rate, and systolic blood pressure?

Newborn 0 to 1 month: heart rate 100 to 160 bpm, respiratory rate 35 to 60/min, systolic blood pressure 50 to 70 mmHg.

Infant 1 to 12 months: heart rate 80 to 140 bpm, respiratory rate 30 to 40/min, systolic blood pressure 70 to 100 mmHg.

Toddler 1 to 3 years: heart rate 80 to 130 bpm, respiratory rate 20 to 30/min, systolic blood pressure 70 to 110 mmHg.

Preschool 3 to 6 years: heart rate 80 to 110 bpm, respiratory rate 20 to 30/min, systolic blood pressure 80 to 110 mmHg.

School age 6 to 12 years: heart rate 70 to 100 bpm, respiratory rate 20 to 25/min, systolic blood pressure 80 to 120 mmHg.

Adolescents 12+ years: heart rate 60 to 90 bpm, respiratory rate 15 to 20/min, systolic blood pressure 100 to 120 mmHg.

What does the ABCDE primary assessment include in a seriously ill child?

ABCDE stands for Airway, Breathing, Circulation, Disability, and Exposure. Airway and breathing assessment includes looking, listening, and feeling for airway obstruction or respiratory distress, work of breathing, respiratory rate, stridor or wheeze, air entry, cyanosis, and oxygen saturation.

Circulation includes heart rate, pulse volume, capillary refill time, and blood pressure if indicated.

Disability includes level of consciousness using AVPU, posture such as hypotonia, decorticate or decerebrate posturing, and pupil size and reactivity.

Exposure includes looking for fever, rash, bruising, trauma, smell such as ketones or alcohol, scars, MedicAlert bracelet, and checking blood glucose in the focused secondary assessment.

What is AVPU, and what is the significance of a child scoring “P” on this scale?

AVPU is a rapid method to assess level of consciousness:
A = Alert, V = responds to Voice, P = responds to Pain, U = Unresponsive.
A score of P is especially important because it means the child’s airway is at risk and may need to be maintained with an airway manoeuvre or adjunct.

A more detailed neurological assessment can then be performed using the Glasgow Coma Scale.

How is capillary refill time assessed, what is considered abnormal, and what important limitation should be remembered?

Capillary refill time is assessed by pressing on the skin of the sternum or a digit at the level of the heart, applying blanching pressure for 5 seconds, and measuring the time for colour to return.

A refill time greater than 2 seconds is prolonged and may suggest poor perfusion. However, it is affected by exposure to a cold environment, so this limitation should be considered when interpreting the result.

What is the usual cause of cardiopulmonary arrest in children, and how does it differ from adults?

In adults, cardiopulmonary arrest is commonly cardiac in origin, often secondary to ischaemic heart disease.
In previously well children with healthy hearts, cardiopulmonary arrest is usually secondary to hypoxia caused by respiratory failure, neurological failure, or shock. This is why prevention through early recognition and treatment of deterioration is especially important in paediatrics.

What are the essential steps of paediatric basic life support (BLS) described in the lecture?

Paediatric BLS begins with safety, assessing danger, and shouting for help.
The child is stimulated gently and the rescuer checks responsiveness, then opens the airway using head tilt-chin lift, or jaw thrust if needed.
In infants the head should be kept in a neutral position and overextension should be avoided.
Breathing is checked for no more than 10 seconds by looking for chest movement, listening for breath sounds, and feeling for air movement.
If the child is not breathing normally, give 5 rescue breaths and remove any obvious obstruction under direct vision.
Then assess for signs of life and pulse for up to 10 seconds,
using carotid or femoral pulse in children older than 1 year and
brachial or femoral pulse in infants.
If there are no signs of life or no definite pulse above 60/min, start chest compressions at 15 compressions to 2 breaths, with a rate of 100 to 120 compressions per minute.
If alone, give about 1 minute of resuscitation before seeking help if possible.

How should chest compressions be performed in infants, small children, and larger children during paediatric BLS?

In infants, the ideal two-rescuer technique is two thumbs placed on the lower half of the sternum with the hands encircling the thorax;
if alone, the sternum may be compressed with two fingers.

In a small child, the heel of one hand is placed over the lower half of the sternum.

In a larger child, both hands may be used over the lower half of the sternum.
In all age groups, the sternum should be depressed by at least one-third of the chest depth, which is about 4 cm in an infant and 5 cm in a child. The rescuer should push hard, push fast, allow full recoil, and avoid unnecessary interruptions.

What are the important details of paediatric advanced life support (PALS) for airway, breathing, and circulation?

Paediatric advanced life support is provided by health professionals with equipment.
It starts with the same airway and breathing principles as BLS, but uses positive-pressure ventilation, preferably with bag and mask, and 100% oxygen.
If required and if a skilled operator is present, an advanced airway such as endotracheal intubation or a laryngeal mask can be used.
Circulation is supported with 15 compressions to 2 breaths at a compression rate of 100 to 120/min.
If the child is intubated, chest compressions are continuous and ventilation rates depend on age: infants about 25/min, age 1 to 8 years about 20/min, age 8 to 12 years about 15/min, and older than 12 years about 10 to 12/min. Intravenous access should be established, or intraosseous access if IV access is delayed.

What formulas and emergency access details are given for paediatric endotracheal tube sizing and intraosseous infusion?

Internal diameter of the endotracheal tube in mm = (age/4) + 4;
oral tube length in cm = (age/2) + 12;
and nasal tube length in cm = (age/2) + 15.

For intraosseous infusion, a tibial route can be established using an 18-gauge trocar with needle on the anterior surface of the tibia, about 2 to 3 cm below the tibial tuberosity.

These formulas and techniques are especially useful because drug doses and equipment sizes vary widely with child size, and exact body weight is often not available immediately.

How are shockable and non-shockable rhythms managed in paediatric advanced life support?

Shockable rhythms are ventricular fibrillation and pulseless ventricular tachycardia.
They are treated with a shock of 4 J/kg followed immediately by 2 minutes of CPR with minimal interruption.
Adrenaline is given every 4 minutes after the third shock and then on alternate cycles, and amiodarone is given after the third and fifth shocks.

Non-shockable rhythms are pulseless electrical activity and asystole. These are managed with immediate CPR for 2 minutes, minimal interruption, adrenaline as soon as possible and then every 4 minutes on alternate cycles, while also looking for reversible causes using the four Hs and four Ts.

What post-cardiac arrest care targets are highlighted in the lecture?

After return of spontaneous circulation, care should continue with the ABCDE approach. Important goals are oxygen saturation of 94% to 98%, normal arterial carbon dioxide, avoidance of hypotension, targeted temperature management, and glucose control. These measures help reduce secondary injury after the arrest.

What are the four Hs and four Ts in paediatric arrest, and what treatments are paired with them in the lecture?

The four Hs are hypoxia, hypovolaemia, hypothermia, and hypokalaemia or hyperkalaemia.
Their treatments include oxygen during ventilation for hypoxia, intravenous saline or blood for hypovolaemia,
warming with blankets and warm IV fluids for hypothermia, and
correction of potassium abnormalities such as IV potassium for hypokalaemia or IV salbutamol, insulin, and dextrose for hyperkalaemia.

The four Ts are tension pneumothorax, tamponade of the heart, toxins, and thrombus.

Treatments include needle thoracocentesis for tension pneumothorax, needle pericardiocentesis for tamponade, reversal agents when available such as naloxone for opiates in toxicity, and thrombolysis or anticoagulation for thrombus.

What clinical features indicate moderate or severe respiratory distress in infants?

Moderate respiratory distress in infants includes tachycardia, respiratory rate greater than 50/min, nasal flaring, grunting, use of accessory muscles, intercostal and subcostal recession, head retraction, and inability to feed.

Severe respiratory distress includes cyanosis, exhaustion, reduced conscious level, oxygen saturation below 92% despite oxygen therapy, and rising partial pressure of carbon dioxide.

These features are important because respiratory failure must be recognized early before decompensation occurs.

How is respiratory support escalated in a child with respiratory failure, and when should oxygen be given?

Respiratory support can be escalated stepwise from supplementary oxygen by face mask or nasal cannula, to non-invasive ventilation including high-flow nasal cannula therapy, and then to endotracheal intubation with mechanical ventilation if needed.

Supplementary oxygen should be administered when SpO2 is less than 92% in order to restore normal saturation. Assessment should still follow ABCDE, with special attention to breathing effort and the effects of hypoxaemia on the heart and brain.

What are the practical points about airway obstruction and bag-mask ventilation emphasized in the lecture?

In airway obstruction, unconscious children commonly obstruct their airway and may need airway-opening manoeuvres or oral or nasopharyngeal airways. Any foreign material should be removed only under direct vision; blind finger sweeps are not advised.
A child with partial obstruction from conditions such as croup or epiglottitis should be kept calm and allowed to remain in the position that best maintains comfort and air entry, because distress or forced examination can worsen obstruction.

For bag-mask ventilation, only the force and tidal volume needed to make the chest rise should be used, excessive pressure or volume should be avoided, cricoid pressure may reduce gastric inflation, the stomach may need deflation, and in two-rescuer technique one rescuer uses both hands to maintain airway and mask seal while the second squeezes the bag and both verify chest expansion.