MANAGEMENT OF CHILDREN IN EMERGENCIES

Pediatric Critical Care Division Child Health Department, Faculty of Medicine University of Indonesia

Emergency sign Priority sign Non Urgent

Triage

Emergency sign
CNS Respiratory Cardiovascular Gastrointestinal Endocrine Etc

PAT ABCDE

The PAT

Circulation to Skin

Appearance (Tickles =TICLS)

Tonus Interactiveness Consolability Look/Gaze Speech/Cry

Work of Breathings
Abnormal airway sounds Abnormal positioning Retractions Nasal flaring

Circulation to Skin
Pallor Mottling Cyanosis
Circulation to Skin

Respiratory distress

Shock

N Primary CNS dysfunction/ metabolic abnormality

N Cardiopulmonary failure

The ABCDEs

Airway Breathing Circulation Disability Exposure

Airway Assessment
Clear Maintainable Unmaintainable

without intubation Obstructed

Breathing Assessment
Rate
Effort / mechanics Air entry

Skin color

Respiratory Rate by Age

Age (years) Respiratory rate (breaths per minute)

<1 2-5 5-12 >12

30-40 20-30 15-20 12-16

Circulation Assessment
Heart rate
Systematic perfusion
Peripheral pulses

Skin perfusion
Appearance (Urine output)

Blood pressure

Heart Rate by Age

Age Newborn 3 mos Range 85 200 bpm

3 mos 2 yrs
2 10 yrs

100 190 bpm

60 140 bpm

Skin Perfusion
Extremity temperature
Capillary refill Color
Pink
Mottled Pale

Blue

Minimal Systolic Blood Pressure by Age

Age
0 1 Mo > 1 mo 1 yr > 1 yr
Fifth percentile mmHg Systolic BP

60 70 70 + (2 x age in years)

Disability (neurologic status)

Cerebral cortex Brain Stem Motor activity

Level of Consciousness

A = Awake V = Responsive to voice P = Responsive to pain U = Unresponsive

Brain Stem

Posture Central respiration Pupil response Cranial nerve

Motor Activity

Symmetrical movements Seizures Posturing Flaccidity

Exposure

Skin rashes Bruises Excoriation etc.

Classification of Physiologic status

Stable
Respiratory dysfunction Potential respiratory failure Probable respiratory failure Shock Compensated Decompensated Cardiopulmonary failure

Case Scenario 1
15-month-old child History Diarrhea, vomitting for 3 days Refused bottle this morning Sleepy, lethargic today

Physical Examination
PAT: A : Very lethargic child in mothers lap

WB: Normal CS : mottled ABC

A : clear B : RR 45/min, breath sounds clear bilaterally C : HR 178 regular, BP 90 mmHG systolic, CRT : > 4 sec, Temp 38oC Weak peripheral pulses Cool, mottled extremities,dry mucous membranes

CNS: V

What would be your approach to this patient?

Initial Approach to the Patient in Shock

Evaluate the ABCs Deliver high concentration of oxygen

Monitor oxygenation and heart rate

Achieve vascular access

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Case Scenario 1: progression

The patient receives oxygen and is placed on a monitor; attempts at peripheral vascular access fail

What would you do now?

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What fluid would you give? How much and how fast?

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Treatment of Shock
Initial rapid fluid administration of 20 mL/Kg of: Crystalloid Colloid Blood