NUR244 TOPIC 6 LECTURE

RECOGNISING AND RESPONDING TO THE SICK CHILD

LEARNING OBJECTIVES

• Gain an understanding of normal assessment findings in the paediatric patient and those indicating deterioration.

• Learn how to recognize a sick or deteriorating child using an appropriate framework.

• Develop an understanding of how to respond to a sick or deteriorating child and provide appropriate respiratory and circulatory support.

• Learn the elements of paediatric cardiopulmonary resuscitation.

• Consider the importance of supporting families and parental presence during paediatric resuscitation.

RECOGNISING AND RESPONDING

• Nurse Competency: A nurse MUST have the ability to recognize and respond to a sick infant and child.

• Implementation of Projects: Many projects in Australia aim to ensure this ability is taught and supported.

  • Examples: Paediatric Early Warning Tools help clinicians recognize a deteriorating infant or child and know when to escalate care. Tools include:

  • PARROT charts

  • Early Warning Score

  • Sepsis Pathway

• Understanding Deterioration Causes: Understanding the causes of deterioration in a paediatric patient is crucial for enhancing early recognition of problems.

  • Developmental Differences: Due to their stage of development, paediatric patients exhibit anatomical, physiological, and behavioral differences that:

  • Influence their predisposition to develop illness.

  • Affect their ability to respond to the distress caused by disease.

PAEDIATRIC RESPIRATORY CHARACTERISTICS INCREASING RISK OF RESPIRATORY COMPROMISE

Characteristics and Impact

• Obligatory Nose Breathers: Infants are obligatory nose breathers, leading to respiratory difficulties if nares become blocked with secretions.

• Narrow Airways:

  • A small amount of swelling or secretion significantly increases airway resistance, affecting the work of breathing.

• Soft Collapsible Airways:

  • Larger submucosal glands compared to adults.

  • Airway cartilage in newborns is not fully developed, increasing susceptibility to collapse.

  • Over-extension of the head should be avoided.

• Large Tongue and Adenoids:

  • An increased risk of airway obstruction, particularly problematic around 2 years of age.

• Horizontal, Cartilaginous Ribs:

  • Due to lack of ossification, chest wall collapses inwards, observed as intercostal, sternal, and subcostal recession, leading to decreased air entry.

• Immature Intercostal Muscles:

  • Predominantly use diaphragm for breathing; the lack of type II muscle fibers leads to early fatiguing of respiratory muscles, manifesting as head bobbing and seesaw movements between chest and abdomen.

• Less Alveolar Surface Area:

  • By approximately 8-12 years of age, children have nine times the alveoli present at birth.

ADDITIONAL RESPIRATORY RISK FACTORS

• Large Head and Inability to Reposition:

  • Large occipital region can push head forward, obstructing the airway with insufficient muscle strength to reposition themselves for better breathing.

• Higher Metabolic Rates:

  • Greater need for oxygen increases respiratory rates.

• Familiarity with Foreign Objects:

  • Developmental stage where children place objects into their mouth or nose leads to upper airway obstruction, often life-threatening for toddlers.

PAEDIATRIC CARDIOVASCULAR CHARACTERISTICS INCREASING RISK OF CARDIOVASCULAR COMPROMISE

Characteristics and Impact

• Immature Myocardium:

  • Limited ability to increase contractility; stroke volume remains relatively fixed; cardiac output is increased mainly by heart rate.

• Blood Volume:

  • Average 70-80 mL/kg; low total blood volume: approximately 240 mL for a newborn means even small losses can result in shock.

• Blood Pressure Maintenance:

  • Hypotension is a late sign of cardiac compromise; other signs include increased heart rate and capillary refill, as well as perfusion.

• Fluid Depletion Risk:

  • Increased risk due to a large surface area leading to insensible losses; reduced ability to concentrate urine during infancy; large percentage of total body fluids.

• Reduced Metabolic and Physiological Reserve:

  • Infants and children may exhaust from disease states, evident in reduced respiratory rates or heart rates, signifying potential cardiac arrest.

STRUCTURED ASSESSMENT OF THE PAEDIATRIC PATIENT

• Purpose of Framework:

  • Using a framework assists in prioritizing assessment of critical body systems ensuring methodical evaluation.

• Paediatric Assessment Triangle:

  • Primary Assessment Framework:

  • Completion of a rapid "hands-off" assessment.

  • Provides a “first look” at body systems (approx. 30 seconds).

  • Abnormalities must be addressed immediately.

  • Assesses appearance, work of breathing, and circulation to the skin.

PAEDIATRIC ASSESSMENT TRIANGLE

Indicators of Severity in Condition

Appearance

• AVPU Scale: Does the child require stimulation to garner a response?

• Indicators of poor condition:

  • Muscle Tone: Flat or rigid.

  • Interaction with Parents: Not engaging.

  • Crying: Absent or abnormal patterns.

  • Rash: Presence of non-blanching rashes.

Breathing

• Airway compromise may include

  • Respirations: Absent, decreased, moderate, or severe distress.

  • Noisy Breathing: Grunting, gasping, or stridor.

Circulation

• Signs of poor circulation:

  • Pale or cold extremities, mottled skin, cyanosis.

  • Prolonged capillary refill time.

  • Fever: Particularly in children under 3 months.

  • Active Bleeding: Any present.

PRIMARY ASSESSMENT FRAMEWORK

• Early Recognition: Children may present early in serious illness.

• Importance of Targeted Management:

  • Address early signs of respiratory, cardiac, and neurological compromises, preventing illness progression.

• Uncommon Events: Cardiac arrest in children is uncommon and rarely due to primary cardiac disease.

• Structured Approach: Helps identify immediate life threats:

  • Common Causes of Cardiorespiratory Arrest::

  • Hypoxia and respiratory failure (from foreign body, bronchiolitis, asthma, pneumonia, aspiration).

  • Circulatory failure (septic shock, anaphylaxis, severe dehydration, congenital heart disease).

  • Central neurological failure (raised intracranial pressure, meningitis, seizures).

• Basis of Paediatric Early Warning Scores:

NORMAL VALUES

Age-Based Assessment Ranges

Respiratory Rate (per minute)

• Newborn: 30-50 (consider >60 as rapid)

• Infant (1-12 months): 20-30 (consider >50 as rapid)

• Toddler (1-3 years): 20-30 (consider >40 as rapid)

• Child (4-11 years): 15-20 (consider >30 as rapid)

• Adolescent (12 years and older): 16-18 (consider >24 as rapid)

Heart Rate (beats per minute)

• Newborn: 70-190 (Mean: 125) – elevated at the upper end.

• Infant: 80-160 (Mean: 120) – elevated at upper end.

• Toddler: 100-110 – elevated at upper end.

• Child: 80-110 – elevated at upper end.

• Adolescent: 55-90 – elevated at upper end.

Blood Pressure (mmHg)

• Systolic: Depends on age (70-90s) and anatomical variations, evaluated against specific age ranges.

AIRWAY (A) ASSESSMENT

• Airway Patency and Obstruction Signs:

  • Stridor, stertor or snoring, hoarse voice, neck swelling or bruising, airway foreign body.

• Resuscitative Measures:

  • Suction, airway maneuvers, airway adjuncts (oropharyngeal or nasopharyngeal airways), endotracheal intubation, surgical airway.

BREATHING (B) ASSESSMENT

Components

• Effort:

  • Respiratory rate, nasal flaring, grunt, tracheal tug, subcostal or intercostal recession.

• Efficacy:

  • Air entry, chest expansion, oxygen saturations.

• Effects:

  • Heart rate, skin color (note that cyanosis is a late sign), mental status.

• Resuscitation Measures:

  • High flow oxygen via non-rebreathing mask.

  • Consideration for positive end-expiratory pressure (PEEP), bag valve mask ventilation, intubation, and positive pressure ventilation.

CIRCULATION (C) ASSESSMENT

Components

• Cardiovascular Function and Tissue Perfusion: Assessment includes heart rate, pulse volume, capillary refill time, blood pressure (note that hypotension is a late sign).

• Signs of Inadequate Circulation:

  • Effortless tachypnoea, poor peripheral perfusion, agitation or drowsiness.

• Assessment of Cardiac Disease / Heart Failure:

  • Gallop rhythm, cyanosis, absent femoral pulses, hepatomegaly.

• Resuscitation Measures:

  • High flow oxygen; establish IV or IO access for blood investigation; sodium chloride 0.9% bolus (20 mL/kg) with repeats as necessary; early consideration of inotropes; control external bleeding; treat arrythmias; commence CPR and Advanced Paediatric Life Support if there is no cardiac output or signs of life.

DISABILITY (D) ASSESSMENT

Components

• Conscious Level: Assess using Alert, Voice, Pain, Unresponsive (AVPU).

• Pupil Evaluation: Size, symmetry, and reactivity.

• Posturing and Tone Assessment: Decorticate, decerebrate postures.

• Seizure Activity: Monitoring for any signs.

• Blood Glucose Level Assessment.

• Resuscitation Measures: Consider intubation for non-responsive cases; treat raised intracranial pressure (mannitol 20% or sodium chloride 3%); correct hypoglycaemia; manage status epilepticus.

EXPOSURE (E) ASSESSMENT

Components

• Full Exposure: Assess temperature, conduct abdominal examination, check for non-blanching rashes or purpura, urticaria, or angioedema.

• Resuscitation Goals: Aim for normothermia; administer antibiotics for suspected sepsis; treat anaphylaxis; provide analgesia.

RECOGNITION OF THE DETERIORATING CHILD

• Structured Approach: Identify a deteriorating child and impending respiratory, cardiovascular, or central neurological failure.

• Secondary Assessment:

  • Primary survey serves as initial assessment for life-threatening issues.

  • Secondary assessment includes focused history and physical exam in stable patients, aiming to:

  • Obtain complete history.

  • Execute detailed physical examination.

  • Establish clinical diagnosis.

  • Perform necessary laboratory investigations and imaging.

ONGOING ASSESSMENT

• Continuous Reassessment: Ensures the effectiveness of emergency interventions and identifies any missed conditions.

• Monitoring Post-Stabilization: Patients should be monitored for:

  • ECG, pulse rate, respiratory rate, oxygen saturations, blood pressure, temperature.

PAEDIATRIC NEUROLOGICAL ASSESSMENT TOOLS

• AVPU Scale:

  • A = Alert

  • V = responds to Voice

  • P = responds to Pain

  • U = Unresponsive

• Paediatric Glasgow Coma Scale (GCS):

PAEDIATRIC GLASGOW COMA SCALE

RESPONDING TO THE SICK CHILD

• Framework Used:

  • A = Airway

  • B = Breathing

  • C = Circulation

  • D = Disability (neurological compromise)

AIRWAY AND BREATHING MEASURES

• Check for Blockages: Inspecting for secretions; utilize suction as needed.

• Positioning for Support:

  • Infants: Neutral position.

  • Children >1 year: ‘Sniffing’ position.

• Medication for Swelling: Adrenaline nebulizers may relieve upper airway symptoms.

• Oxygen Delivery: Provide age-appropriate oxygenation using the most suitable delivery method.

CIRCULATORY SUPPORT AND DISABILITY MEASURES

Circulatory Support

• Vascular Access: Must be established upon admission; difficult during crises.

• Crisis Management: Attempt IV access for no longer than 60 seconds; if unsuccessful, consider:

  • Central venous line or intraosseous needle for emergency access.

Disability Monitoring

• Monitor conscious state closely.

• Assess the need for intubation if condition worsens.

PAEDIATRIC LIFE SUPPORT

Basic Life Support

• Efforts to restore or maintain airway, breathing, and circulation without adjunct equipment (e.g., a bystander CPR).

Advanced Life Support

• Incorporates basic life support with more invasive measures (e.g., airway management, intubation, IV access, and defibrillation).

AGE-BASED RESUSCITATION GUIDELINES

Pulse Check Protocol

• Age Ranges:

  • Infant <1 year

  • Child 1-8 years

  • Older child >8 years

Head Tilt Position

• Infants: Neutral position.

• Children: Slightly extended sniffing position from 1 year.

• Older Children: Semi to full extension head tilt with chin lift.

Compression Site and Methods

• Compression Site: Centrally on the lower half of the sternum.

• Compression Delivery Method:

  • Infants: Pressure with two thumbs or fingers.

  • Children: Pressure with the heel of one hand; older children use heel of one hand with the other hand superimposed.

Compression Depth and Rates

• Compression Depth:

  • Infants: 4 cm, approx one-third depth of chest.

  • Child: 4-5 cm, approx one-third depth.

  • Older Child: 5 cm, approx one-third depth.

• Compression: Ventilation Ratio:

  • Basic Life Support: 30:2, cycles per 2 minutes.

  • Advanced Life Support: 15:2, cycles per minute.

• Compression Rate:

  • Irrespective of age: 100-120 compressions per minute; complete 5 cycles per minute.

PARENTAL PRESENCE DURING RESUSCITATION

• Findings from Research: An Australian study revealed that parents who did not witness their child's resuscitation experienced greater distress compared to those who were present (Maxton, 2008).

REFERENCES

• Australian and New Zealand Committee on Resuscitation (ANZCOR) 2021 Guideline 12.1 – Paediatric Basic Life Support (PBLS) for health professionals. ARC Canberra.

• Fraser, J., Waters, D., Forster, E. and Brown, N. (2022) Paediatric Nursing in Australia and New Zealand (3rd Ed) Cambridge University Press.