Paediatric Emergencies PDF

Paediatric emergencies Dianne Crellin, Michelle McCarthy Essentials Accurately assessing and appropriately managing paediatric emergencies are contingent on having a good understanding of growth and development, and of the anatomical and physiological impact of immaturity and its eﬀect on acute illness and injury across all systems. Eﬀective collaborative healthcare is contingent on developing a therapeutic relationship with the patient and their family. Gaining the trust and cooperation of children requires an understanding of cognitive and emotional development and a ﬂexible approach to assessment and management. The principles of assessment and management of infants and children are the same as for adults, so this chapter should be read in conjunction with other chapters in the book addressing the topic. A number of tools are available to guide paediatric history-taking and examination to ensure that issues speciﬁc to children are not overlooked and that clinical ﬁndings are aﬀorded the relevance warranted. However, the principles of assessment, triage and management for infants and children are the same as they are for adults presenting to the emergency department (ED). Infants may rapidly deteriorate, and frequently exhibit few or non-speciﬁc signs and symptoms of signiﬁcant illness as a result of immunological immaturity. For this reason, in addition to the a ention given to the signs and symptoms of the illness, particular a ention should be paid to feeding, urine output, activity levels and sleeping pa erns. Respiratory illnesses are the most common illnesses occurring in children and account for 30–40% of acute admissions to hospital. As the aetiology is most frequently viral, treatment is focused on managing the symptoms of illness. Infants are particularly susceptible to shock as this compensatory mechanism is easily overwhelmed, and unless aggressively treated the physiological derangements of shock rapidly become irreversible. Infants and young children are also particularly susceptible to dehydration during episodes of illness, regardless of the type of illness, and hydration should be a focus of assessment and management of the unwell child. Changes in conscious state are also a feature of deterioration, regardless of the type of illness and should not be overlooked. Rashes can be grouped by appearance as vesicular, pustular, papular, eczematous, purpuric/vascular and erythematous, which will help determine the likely cause and therefore appropriate management. Trauma is a major cause of mortality and morbidity in infants, children and adolescents. The injuries infants and children suﬀer and their response to trauma is aﬀected by their size and their level of physical and cognitive development. Fever is a common symptom associated with illness in children and causes great concern in the community. However, management should be focused on providing comfort. Treatment of fever in most circumstances is not recommended. Furthermore, antipyretics are not recommended in the absence of signs of discomfort or to prevent convulsions. Children are less likely to receive analgesia than adults in the ED se ing, and infants and young children are less likely to receive analgesia than older children. Management should include adequate analgesia regardless of the cause of the pain. Acute healthcare is the principal priority during the emergency visit; however, it is also an opportunity for emergency clinicians to provide health education and address other health and lifestyle issues, such as immunisation, smoking cessation and weight management. Introduction Paediatrics is considered a specialty and it is often said that children are ‘not li le adults’. However, most children assessed and treated by emergency services are not seen by paediatric specialists but by emergency clinicians, who require the skills to assess and manage both adults and children competently. Using a systematic approach to assessment and applying simple principles, it is possible to adequately assess and identify health-related problems in children presenting to emergency services and manage them eﬀectively. It is not intended for this chapter to provide an exhaustive list of potential paediatric presentations. The aim of the chapter is to address the key diﬀerences that exist between infants, children and adults, and present some common and important paediatric presentations to emergency service providers. Where the presentation does not diﬀer greatly from the adult and this is presented elsewhere in the book, these presentations have been omi ed. For those that are presented in other chapters, but where the paediatric presentation diﬀers, discussion in this chapter will chieﬂy focus on these diﬀerences. A list of useful websites and additional reading materials have also been included at the end of the chapter. Approach to paediatrics Anatomy and physiology Accurately assessing and appropriately managing paediatric emergencies is contingent on having a good understanding of growth and development and of the anatomical and physiological impact of immaturity and its eﬀect on acute illness and injury across all systems. Children grow in size and mature anatomically and physiologically until they reach adulthood. However, this is not uniform; for example, physiological maturity of many systems is achieved by the end of infancy, while skeletal maturity is not achieved until after puberty. This means that young children may have similar physiological responses to illness and require similar management to adults, while in other circumstances their responses and management may vary greatly. These diﬀerences and their implications will be discussed throughout the chapter in relevant sections of the text. Table 35.1 supplements this discussion and should be consulted for a more comprehensive list of the anatomical and physiological diﬀerences that exist between adults, infants and children and their clinical signiﬁcance. TABLE 35.1 The anatomical and physiological differences between infants, children and adults, and their clinical significance DIFFERENCE DISCUSSION Airway diﬀerences Airways Foreign ma er such as blood, mucus, vomit and —smaller teeth easily obstruct small airways —more airway soft tissue Small amounts of oedema may obstruct the airway, markedly increasing airway resistance Tongue—larger relative to Airway may be obstructed by the tongue, where the oropharynx there is swelling or a decrease in conscious state Obligate nose breathers in early infancy (< 3 months of age) Trachea—shorter in length Obstructed nasal passages can produce signiﬁcant respiratory distress and/or feeding diﬃculty Increased chance of bronchial intubation Changes in head position will cause movement in ETT Flexion of the neck displaces the tube further into the trachea Extension of the neck moves the tube further out of the trachea Larynx—softer and more More susceptible to compression with cartilagenous hyperextension or hypoextension of the neck Larynx—positioned more Increased risk of aspiration anteriorly and cephalad Direct visualisation of the vocal cords is more diﬃcult during intubation Cricoid cartilage—the Cricoid ring provides a natural seal for the narrowest region of the endotracheal tube airway rather than the larynx Cuﬀed tubes may cause airway damage in younger children Epiglo is—shaped Epiglo is likely to ‘ﬂop’ into airway obscuring view diﬀerently and relatively of cords during intubation ﬂoppy Occiput—relatively large Head pushed forward when lying supine, therefore neck not in neutral alignment; may result in airway compression Cervical spine diﬀerences Head—proportionately Increases the risk that vertebrae may move, heavier resulting in spinal cord injury in the absence of a Vertebral ligament— fracture increased laxity Pseudosubluxation of C2 on C3 Neck musculature— Normal variant in up to 40% of children aged < 7 underdeveloped years and in < 20% of children aged < 16 years Secondary to ligamentous laxity Phenomenon called spinal cord injury without radiological abnormality (SCIWORA); seen predominantly in children Fulcrum of ﬂexion higher— Level of cervical spine injury occurs at fulcrum C1–C2 in young children; of ﬂexion C6–C7 in adults Aﬀects outcome Growth centres in vertebrae Increased susceptibility to shearing forces Ear–nose–throat Eustachian tubes—shorter Reduced drainage of ﬂuids and angle less acute Respiratory diﬀerences Ribs Retractions are more common and reduce the —more cartilaginous infant's or small child's ability to maintain —twice as compliant as functional residual capacity or generate those of an adult adequate tidal volume Ribs may not fracture under compression or with direct blow Provide less protection to underlying organs. Increased chest wall compliance allows traumatic forces to be transmi ed to underlying thoracic structures Ribs—positioned more Relatively ﬁxed tidal volume horizontally in infancy than the adults Mediastinum—more mobile More likely to suﬀer damage due to shearing in an acceleration/deceleration injury CLINICAL IMPLICATIONS Visualisation and clearing of the airway more diﬃcult Suctioning of airway may be required In the trauma patient, open the airway using the jawthrust manoeuvre Repositioning may be the only intervention needed to maintain a patent airway Oropharyngeal airways may be useful in the unresponsive child Remove secretions using saline drops or suction Ensure air-entry to both lung ﬁelds, conﬁrm position on X-ray Secure tube carefully Record initial ETT position (centimetre mark at the gum) Maintain head in midline position and prevent extension or ﬂexion of the neck Monitor ETT position regularly Maintain appropriate position to ensure airway patency Use jaw thrust in the trauma patient Cricoid pressure occludes airway during intubation; may also assist with visualisation of the vocal cords during intubation a empts Use uncuﬀed endotracheal tubes in children younger than 8 years Ensure alternative laryngoscope blade (straight) available Lift epiglo is out of the way Place a small towel roll under the child's shoulders to maintain the appropriate airway position Normal cervical spine X-ray does not exclude cord injury Careful neurological examination needed CT scan and MRI may be useful adjuncts in the evaluation of possible spinal cord injuries Neurosurgical consultation should be obtained where extent of injury unclear Neurological deﬁcits determined by level of injury Increases likelihood of cord injury Increased number of ear infections Work of breathing the most useful indicator of level of respiratory distress Absence of rib fracture on X-ray does not exclude possibility of injury to underlying structures Suspect pneumothoraces and/or haemothoraces in the child who has signiﬁcant chest trauma with or without rib fractures Dependent on rate to maintain minute volume DIFFERENCE DISCUSSION Fatigue-resistant type I ﬁbres Become exhausted more quickly —fewer in intercostal muscles Diaphragm —performs most of the work of breathing —reduced role of intercostal muscles Generation of tidal volume depends on diaphragmatic function Anything impeding diaphragm movement can lead to reduced tidal volume, e.g. distended stomach Diaphragmatic fatigue possible Chest wall—relatively thin Breath sounds are easily transmi ed across the chest wall and over the abdomen Diﬃcult to localise adventitious noises (including upper-airway-generated noises) Oxygen consumption—twice that of an adult Respiratory muscles—greater oxygen and metabolite requirement Control of ventilation— immature Circulatory diﬀerences Myocardium —fewer actomysin elements and mitochondria, therefore less capacity to increase contractility —less compliant Higher minute volume to meet demand Work of breathing can account for up to 40% of the cardiac output, particularly in stressed conditions Responses to hypoxia are unpredictable Unable to increase stroke volume Greater reliance on increases in heart rate to increase cardiac output compared with the adult Higher atrial pressures at the same ﬁlling pressures Negative eﬀect on preload Restricts capacity to increase stroke volume Relatively poor response to aggressive ﬂuid resuscitation Compensation—be er able to May remain normotensive until 25–40% of their mount compensatory blood volume is lost response by increasing Hypotension is a late and often sudden sign of peripheral vascular resistance cardiovascular decompensation Blood volume Smaller amounts of blood loss can cause volume —larger volume per kg depletion (child 80 mL/kg vs adult 70 mL/kg) —absolute volume much smaller Vessels—smaller Intravascular access more diﬃcult Systemic vascular resistance —lower Terminal rhythm diﬀers —children: brady/asystole; adults: VF/VT Fluid balance Percentage total body water larger—infants & children: 80%; adults: 65% Surface area/volume ratio— larger BP lower Renal blood ﬂow and the glomerular ﬁltration rate— lower Renal system—immature Neurological diﬀerences Bradycardia often result of hypoxia Brachycardia not well tolerated in children because it signiﬁcantly reduces cardiac output CLINICAL IMPLICATIONS Closely observe the child with continuous monitoring of heart rate, respiratory rate and eﬀort, and pulse oximetry Treat respiratory distress Prevent increases to demand Allow parents to remain with child if their presence is comforting to the child Provide non-threatening environment and avoid noxious stimuli Treat pain Allow alert child to maintain own position of comfort to optimise respiratory eﬀort If possible, maintain patient in upright position to support diaphragmatic function Avoid abdominal distension Smaller, more frequent feeds Nasogastric or orogastric tube insertion to decompress the stomach Breath sounds should be auscultated bilaterally over the anterior and posterior chest wall, and in the axillary areas, using a paediatric stethoscope Diﬀerences indicating pathology may be subtle Obtain chest X-ray ﬁlms as necessary Deliver highest possible concentration of oxygen to infants and children in respiratory distress Reduce work of breathing Mechanical ventilation to eliminate metabolic costs of work of breathing Monitor young infants closely for apnoea Provide continuous cardiac monitoring with a ention to trends in heart rate Larger volumes of ﬂuid may be required to augment circulation Monitor other parameters to detect hypovolaemia before hypotension apparent Aggressive resuscitation in response to earlier signs of hypovolaemia Carefully estimate blood loss, including blood drawn for laboratory analysis Serial haemoglobin and haematocrit analysis should be obtained Consider blood replacement therapy after 40–60 mL/kg of isotonic crystalloids in the paediatric trauma patient with signs of shock or when acute blood loss totals 5–7% of the child's circulating blood volume Cannula sizes will need to be adjusted Ensure most-competent clinician a empting access in time-critical situation Low threshold for using alternative access strategy, e.g. intraosseous administration Ensure reference range for normal BP for varying age is available Provide adequate oxygenation and ventilation Treat symptomatic bradycardia Infants and young children will lose larger amounts Calculate maintenance ﬂuids based on each child's weight in of water through evaporation than will the adult kilograms and clinical condition Children have greater potential for dehydration Maintenance ﬂuid requirements per kilogram of body weight are higher in children Less capacity to concentrate the urine infants 2 mL/kg children 1 mL/kg adults 0.5 mL/kg Less able to acidify urine and therefore more susceptible to hyperchloraemic acidosis with aggressive resuscitation with Normal saline Record all sources of ﬂuid intake and ﬂuid loss to calculate ﬂuid balance and adjust ﬂuid therapy accordingly Relatively higher volumes of urine are required to indicate adequate renal perfusion Avoid large volume resuscitation with Normal saline without close monitoring of electrolytes DIFFERENCE Head—proportionately larger and heavier DISCUSSION Higher centre of gravity acts as a missile If an infant or child falls or is thrown a signiﬁcant distance, the initial impact more often will be to the head, which predisposes the child to head injury Skull—thinner Provides less protection for the brain Cranial sutures Fullness of fontanelle is inﬂuenced by acute —do not fuse until changes in intracranial volume approximately age 16–18 —full = intracerebral infection, haemorrhage etc months —low = hypovolaemia —fontanelles are junction Allow for growth of the skull and intracranial between sutures contents May allow for gradual increases in intracranial volume, i.e. hydrocephalus Cognitive development— Assessment of cognitive function inﬂuenced by varies with age level of development Cooperation inﬂuenced by development Metabolic and thermoregulatory diﬀerences Immune system—immature Increased susceptibility to infection Response to infection diﬀers; often poorly localised resulting in diﬀerent constellation of symptoms Surface area to body Increased heat loss through radiation and mass ratio—higher evaporation, especially from the child's Subcutaneous fat stores— proportionally large head lower Hypothermia can cause metabolic acidosis, hypoglycaemia, coagulopathies, CNS depression, respiratory depression and myocardial irritability, making resuscitation more diﬃcult Less-well-insulated by fat, adding to heat loss Heat production —infants aged < 3 months unable to rely on shivering —rely on fat stores Glycogen stores—lower Metabolic rate—higher Abdominal diﬀerences Diaphragm—ﬂa ened Abdominal wall—less musculature and less subcutaneous tissue Bladder position—intraabdominal organ until approximately 2 years of age Musculoskeletal diﬀerences Bones —incomplete bone calciﬁcation —more cartilaginous —more ﬂexible and plastic Bones growing—physeal plate and secondary ossiﬁcation centres present CLINICAL IMPLICATIONS Anticipate head injury in the traumatically injured child Suggest use of preventive measures, such as seat belts, car seats and helmets, to patients and family members As above Assess fontanelles for size and tension in the infant age 16–18 months or younger Measure head circumference with neurological examinations in the child up to age 16–18 months at risk for increasing intracranial pressure Use modiﬁed GCS for neurological assessment Use age-appropriate assessment techniques Use age-appropriate management strategies Assume serious illness in babies with generalised symptoms until focus found Prevent heat loss Cover children with warm blankets or place them under warming lights if they cannot be covered Reduce draughts in clinical area Use warmed intravenous ﬂuids or blood for volume resuscitation Warm and humidify supplemental oxygen if possible Consider placing small infants in isole es with overbed warmers Monitor temperature in young babies in isole e with skin probe to avoid underheating or overheating and thermal injury Increased risk of hypothermia in the small infant As above The burning of fat increases oxygen consumption, which can lead to hypoxia Increased risk for developing hypoglycaemia Increased oxygen and glucose consumption Increased demands associated with illness may not be met due to poor stores Results in higher nutritional needs per kilogram of bodyweight than in an adult Monitor glucose frequently during and after resuscitation Administer glucose as ordered As above Provide supplemental oxygen to all seriously ill or injured children Consult with doctor and dietitian to provide early, adequate nutritional support to the compromised child Pushes the spleen and liver down into the abdominal cavity Unprotected by the rib cage, increasing their exposure to injury Spleen and liver are the most commonly injured abdominal organs in children Provides less protection to underlying organs Abdominal assessment for presence of injury vital in children involved in trauma Obtain early surgical consultation as necessary Monitor serial haemoglobin and haematocrit analysis for signs of haemorrhage Abdominal girth measurements may assist assessment As above Increased risk of bladder trauma where there is injury to the abdomen Urine specimens can be taken suprapubically in infants and young toddlers Aﬀord less protection to underlying structures than the stronger, more rigid bones of the adult Can absorb larger amounts of force without bone injury, transferring force to underlying structures Change the injury proﬁle as increased cartilage weakens the bone Weakest part of the musculoskeletal system (tendon/muscle/ligament/bone) Result in plastic deformation (bowing fractures, greenstick and torus fractures) in response to trauma Physeal plate is a point of vulnerability (2–5 times weaker than other parts of the bone) Increased blood ﬂow to physeal areas of the bone increases likelihood of vascular deposition of bacteria, e.g. osteomyelitis Index of suspicion for organ damage should be high even in the absence of fractures where the force was signiﬁcant Obtain early surgical consultation as necessary Monitor for signs of internal haemorrhage Low threshold for X-ray of limb injuries even in the absence of obvious signs of fracture as plastic deformation, torus and buckle fractures less clinically apparent Presence of secondary ossiﬁcation centres and physeal plates inﬂuence interpretation of radiological images Gain paediatric orthopaedic opinion if there is any doubt about images Index of suspicion for infection should be high DIFFERENCE Bones growing—metabolic activity higher DISCUSSION Healing times are substantially shorter Growing bones allow for remodelling of the bony deformity particularly in the arc of movement CLINICAL IMPLICATIONS BP: blood pressure; CNS: central nervous system; CT: computed tomography; ETT: endotracheal tube; GCS: Glasgow Coma Scale; MRI: magnetic resonance imaging; VF: ventricular fibrillation; VT: ventricular tachycardia Family-centred care and communication In most circumstances, children present with a parent or caregiver who plays an integral role in maintaining the health and welfare of the child. Emergency care of children includes caring for the family unit, and this should be collaborative and based on a partnership. Parents and caregivers must be given the opportunity to negotiate their role in treatment decision-making and caring for their children and where children are old enough they should be included in this collaboration. Please refer to Chapter 8 for a detailed discussion of patient-centred care and communication. Eﬀective collaborative healthcare is contingent on developing a therapeutic relationship with the patient and their family, and the circumstances of emergency care can make this more diﬃcult as time is limited and patients and their families are usually anxious and worried. This challenge is magniﬁed when communication with the patient is made more diﬃcult because of their condition or their age. Paediatric emergency presentations require clinicians to rapidly develop rapport with adults and children whose needs may be diﬀerent, and the ways that these needs can be met are likely to be diﬀerent. Parents experience a range of emotions when calling an ambulance or presenting with their children to the emergency department (ED); these may range from relief to great anxiety about the likely diagnosis and outcome, or guilt about the origins of the child's illness or injury. The parents may also have a range of concerns that they are reluctant to raise unless comfortable. Furthermore, they are likely to have had previous contact with healthcare professionals, which may even include consultation for this health concern, and their experiences may range from favourable to very unsatisfactory, which may colour their a itude towards this presentation. Complaints about the quality of healthcare will include those where the diagnosis was missed, and treatment decisions were wrong. However, a large number focus on communication and the interactions between patients, families and clinicians. Parents most frequently complain that they were not listened to or taken seriously, or that they weren't provided with suﬃcient information. Developing good rapport with parents and caregivers requires the clinician to listen carefully to the parents’ concerns, ideally while seated, and not to interrupt. The circumstances of emergency care pre-hospital, at triage and during the diagnostic work-up and treatment phases of the emergency presentation can make this especially diﬃcult to achieve. Simple strategies may help to overcome the limitations of the circumstances, such as using the parents’ and child's names. Regardless of how minor the health problem, the parents’ concerns should be acknowledged. Parents are often seeking information and reassurance, and this should be provided wherever possible. Clinicians should be aware of their own body language, the language that they use and the messages that this may convey. For example, asking a question using ‘why’, such as ‘Why have you come today?’, implies that they should have done something diﬀerent. Explanations should be provided in language that parents will understand and should not include jargon, abbreviations and acronyms. Most children are discharged home where parents or family members will care for them, which makes it essential that they understand the information they were provided. Discharge education should provide families with suﬃcient detail to adequately and conﬁdently manage their child at home. It should always include a comprehensive discussion of the criteria for re-presentation. Worsening of the symptoms of the viral illness or development of secondary infection may result in signiﬁcant deterioration warranting review and treatment. On occasions the diagnosis is diﬃcult to make in the early stages of the illness and review may be necessary to identify the speciﬁc features of illness. Parents must be given the capacity to recognise signs of treatment failure and deterioration and the conﬁdence to return to the ED for review. Gaining the child's conﬁdence will improve the child's cooperation with history-taking and with the examination and may help to reassure the parents. The strategies used to gain the conﬁdence of the child will depend on their age and rely on showing creativity and an understanding of the cognitive development of the child and their likely fears. Infants and young children will look to their parents for support and they should not be separated unless absolutely necessary. Age-appropriate games and toys may be used to distract and help gain the child's conﬁdence. These strategies serve as a way of relaxing the child, but are also an excellent aid to examination. For example, an infant watching and reaching for bubbles demonstrates normal cognition. Where possible, examination should be delayed until the child has become more comfortable with the clinician. The best results are generally achieved when the child is examined in a parent's arms or on their lap with the clinician si ing on a low stool or on the ground rather than standing over the top of the child. The sequence of examination should see the more invasive and distressing techniques left until last. As children get older, involving them as much as possible and explaining your intentions is likely to increase the child's conﬁdence. Great care should be taken with the language used, as school-aged children can be very frightened by particular words and can take expressions quite literally. Magical thinking can exacerbate this but is also an excellent foundation for age-appropriate games aimed at gaining their cooperation. It may be possible to make a game out of parts of the examination: for example, explaining that you think you saw a tiger in their ear, but you need to use a light to have a proper look to see if there really is one there. Reading stories and watching videos can also serve to distract the child. Once children reach adolescence, they are usually striving for much more independence and are likely to look for this when seeking healthcare. However, this should not be assumed, and clinicians will need to negotiate everyone's roles fairly early on. Generally, this needn't be done formally as it becomes increasingly apparent during the consultation. Privacy Privacy should be provided for paediatric consultations regardless of the age of the child or the nature of the presentation. Simple health problems may be an opportunity for parents to seek assistance from healthcare professionals regarding more sensitive issues. Adolescents are also likely to demand greater privacy and may also wish to discuss their health concerns without the presence of their parents. Practice tips Approach to paediatrics Infants and children diﬀer from adults anatomically, physiologically and cognitively, and this must be considered when examining and managing them in the ED. It is essential to rapidly gain the trust of the parents and the child to assess and manage the child in the ED. Most complaints stem from poor communication. Strategies for engaging with the child and gaining their cooperation will depend on their age. Parents and/or caregivers must be given the opportunity to negotiate their role in clinical decisionmaking and caring for their children. Privacy for children and their families (regardless of age) should be maintained. Assessment The physical, cognitive and developmental diﬀerences between infants, children and adults will inﬂuence the approach to assessment and interpretation of the ﬁndings. Using a systematic approach to assessment and applying some simple principles, it is possible to adequately assess and identify health problems in infants and children. The following sections describe an approach to paediatric health assessment and highlight how the diﬀerences between adults, children and infants aﬀect assessment. History The history will provide information about the chief presenting complaint, associated signs and symptoms, past medical history, family history and social history, which will identify health-related concerns and aid the diagnosis and development of a management plan for the child and their family. The focus of the history and the extent of the detail sought must also be tailored for the circumstances of the presentation (i.e. mechanism of injury where the child presents with an arm injury), the age of the patient (i.e. perinatal history where the child is < 3 months of age), the environment (i.e. pre-hospital or ED) and the urgency of the presentation. History-taking requires signiﬁcant interview skills to ensure that the history is complete, regardless of the age of the patient. However, there are some unique features to paediatric history-taking where it relies on building a rapport with both patient (child) and parent, as discussed in the previous section. History-taking in paediatrics often relies on information provided by primary carers, with the child's involvement limited by their level of cognitive development and the extent of their illness. However, it is important not to ignore the contribution that may be made by quite young children. Young children are often capable of providing important details, while parents may be less clear about the circumstances of the injury or illness of their child. For example, a child with an arm injury may be able to conﬁrm that the injury occurred once another child helped pull her up onto the play equipment and not from the fall as may have been assumed by a parent, supporting a diagnosis of ‘pulled elbow’ rather than ‘fracture’. Additionally, siblings may also provide valuable information, particularly descriptions of the mechanism of injury responsible for the child's presentation. Patient history generally focuses on details about the chief presenting complaint, past medical history that includes treatments and current medication regimens, social history and family history. Paediatric history-taking may adopt this framework with details about speciﬁc paediatric health-related issues such as perinatal history collected under the relevant headings. Alternatively, mnemonics such as CIAMPEDS (see Table 35.2) have been designed to prompt clinicians to collect relevant data.1 TABLE 35.2 CIAMPEDS mnemonic to guide history-taking for the paediatric presentation1 ELEMENT OF MNEMONIC Chief complaint Immunisation status/Isolation DESCRIPTION Identify the reason for the ED visit Conﬁrm the immunisations that the child has received to date and record the reasons for delays or decisions to omit an immunisation Identify potential exposure to infectious diseases, e.g. parvovirus, and note the source, e.g. sibling, childcare, etc Allergies Document a history of previous allergic or hypersensitivity reactions and include the type of reaction Medication Record all medications currently prescribed, those being taken and medications recently ceased. Include overthe-counter medications and herbal preparations Past medical Record details of past health problems. Include prior illnesses, injuries, hospital admissions, surgical history/Parent's/caregiver's procedures and chronic physical and mental health problems. In older children include risk-taking behaviour impression of the child's such as: alcohol, tobacco, drug use. condition Identify the child's primary caregiver(s). Document their impression of the illness/injury, noting their speciﬁc concerns, which may be inﬂuenced by a range of factors, including: culture, previous experience of illness and healthcare Events surrounding the illness or Document the time course of the illness or time of the injury. Note the associated circumstances, precipitants injury and alleviating factors and the mechanism of injury for traumatic presentations Diet and diapers (nappies) Note recent oral intake, paying particular a ention to ﬂuids. Identify recent changes in eating pa erns and consider weight changes Urine and stool output Symptoms associated with the Identify symptoms and their pa ern of progression over the course of the illness or since the time of injury illness or injury Presenting complaint Determining the nature of the presenting complaint and the associated signs and symptoms is the initial focus of history-taking. This is a detailed account of the onset of the illness or the mechanism of injury, the range and extent of signs and symptoms, the precipitating and alleviating factors and the treatment provided to date. There are some clinical and age-related factors that should be considered as they may alert the clinician to the presence of signiﬁcant illness or injury. Infants may rapidly deteriorate, and frequently exhibit few or non-speciﬁc signs and symptoms of signiﬁcant illness as a result of immunological immaturity. For this reason, in addition to the a ention given to the signs and symptoms of the illness, a ention should be paid to feeding, urine output, activity levels and sleeping pa erns. Research has shown that changes to any of these increases the likelihood that the infant or young child has a serious illness, and with the addition of a urine screen most infants with serious illness can be detected by reviewing these simple parameters.2,3 Furthermore, these details may also provide clues about the nature of the illness. Poor feeding may result from shortness of breath, lethargy or general malaise, and is associated with a range of illnesses, which include serious infection, moderate to severe respiratory illness and gastrointestinal disorders. The relationship between other symptoms and feeding should also be explored. In neonates and young babies, sweating and dusky skin colour during feeding suggests cardiac disease, while projectile vomiting soon after feeding suggests pyloric stenosis. Comparison with the feeding pa ern of the child or infant when well is generally the best method for determining the adequacy of feeding and this information can be provided by the carer. However, it is useful to know the average volumes consumed by infants and children at varying ages, and these can be found in Table 35.3. Similarly, changes in urine output are best estimated by comparing current output with output when well; in infants this is determined indirectly via the number of wet nappies in a day. It is generally accepted that infants will have approximately six wet nappies per day. TABLE 35.3 Average oral intake for neonates, infants and children AGE Infant Small child Older child VOLUME 150 mL/kg/day 50 mL/kg/day 20 mL/kg/day Serious illness in infants can be associated with irritability and disturbed sleep, or decreased activity and drowsiness, where the infant fails to wake for feeds. Sleep may also be disturbed by respiratory illness, shortness of breath, sleep apnoea caused by enlarged tonsils, pain and a range of other circumstances. Past history A child's co-morbidities and treatment and the potential eﬀect on their acute condition should be considered. This should also include the infant's perinatal history, to identify health problems resulting from prematurity, the circumstances of the delivery or congenital abnormalities. For example, the infant with congenital lung disease resulting from prematurity is at risk of more signiﬁcant respiratory dysfunction associated with an acute respiratory infection. The history should determine whether the child is showing consistent weight gain and meeting normal growth and developmental milestones. Some illnesses and abnormalities become evident as a result of failure to thrive or arrested/delayed development. For this reason, it is important to be familiar with developmental milestones and the use of growth charts to identify deviations from normal; refer to Table 35.4 for normal milestones in the ﬁrst two years of life. Newborns in Australia and New Zealand are issued with an ‘infant welfare’ book (variously named in diﬀerent jurisdictions) to document postnatal and maternal child health nurse examinations, including weight measurements and immunisations. There are also several tools available that document growth and development norms, i.e. height and weight charts, developmental screening tools (Denver development tool), etc. TABLE 35.4 Normal milestones in first two years of life6 AGE Neonate 6 weeks 2–4 months 5–8 months 9–12 months 12–16 months 17–21 months 2 years ACHIEVEMENT—MOTOR Lifts head Visually ﬁxes for period Follows past midline Rolls over Head steady when si ing Follows objective 180 degrees Sits without support Transfers objects between hands Stands holding on for support, crawls Able to use a pincer grip for small objects Walks unassisted Able to make a stack of two blocks Walks up steps Scribbles with large texta/crayon Runs and jumps Can copy drawing straight line ACHIEVEMENT—LANGUAGE AND SOCIAL Turns to voice Smiles Smiles Squeals with enjoyment Makes babbling noises Feeds self biscuit Says ‘mama’ and ‘dada’ Exhibits stranger anxiety Indicates needs by gesturing Says single words Drinks from a cup Says several words Points to one part of the body Combines words Can remove clothing The immunisation schedule provides recommendations for the vaccination of children against a range of childhood diseases. Table 35.5 lists the Australian4 and New Zealand5 schedules that are governmentfunded. When gaining a history, it is important to ask about the immunisation status of the child. Details should be obtained when vaccinations were administered overseas, where the schedule may vary from the Australasian schedules. Although it is uncommon for children to be unimmunised, many children fall behind the schedule, often as a result of illness at the time vaccinations were due. A small number of families will identify themselves as conscientious objectors to immunisation or will indicate that they have had their child homeopathically immunised. This is addressed in more detail in a later section focusing on preventative health. TABLE 35.5 Immunisation schedules7,8 AGE DISEASES AND VACCINES Australian recommended immunisation schedule (implemented November 2016)* Birth Hepatitis B (hepB)a 2 months Hepatitis B, diphtheria, tetanus, acellular pertussis (whooping cough), Haemophilus inﬂuenzae type b, inactivated poliomyelitis (polio) (hepB-DTPa-Hib-IPV) Pneumococcal conjugate (13vPCV) Rotavirus 4 months Hepatitis B, diphtheria, tetanus, acellular pertussis (whooping cough), Haemophilus inﬂuenzae type b, inactivated poliomyelitis (polio) (hepB-DTPa-Hib-IPV) Pneumococcal conjugate (13vPCV) Rotavirus 6 months Hepatitis B, diphtheria, tetanus, acellular pertussis (whooping cough), Haemophilus inﬂuenzae type b, inactivated poliomyelitis (polio) (hepB-DTPa-Hib-IPV) Pneumococcal conjugate (13vPCV) Rotavirusb 12 months Haemophilus inﬂuenzae type b and Meningococcal C (Hib-MenC) Measles, mumps and rubella (MMR) 18 months Diphtheria, tetanus, acellular pertussis (whooping cough), measles, mumps, rubella and varicella (chickenpox) (MMRV) 4 years Diphtheria, tetanus, acellular pertussis (whooping cough) and inactivated poliomyelitis (polio) (DTPa-IPV), measles, mumps and rubella (MMR) Only if MMRV not given at 18 months 10–15 years Varicella (chickenpox)c Human papillomavirus (HPV)d Diphtheria, tetanus and acellular pertussis (whooping cough) (dTpa) Aboriginal and Torres Strait Islander children in high risk areas 12–18 months Pneumococcal conjugate (13vPCV) 12–24 months Hepatitis A (Aboriginal and Torres Strait Islander children in high risk areas)f 18–24 months Pneumococcal polysaccharide (23vPPV) (Aboriginal and Torres Strait Islander children in high risk areas) Hepatitis A (Aboriginal and Torres Strait Islander children in high risk areas) 15 years and over Inﬂuenza (ﬂu) Pneumococcal polysaccharide (23vPPV) Other at risk groups 6 months & over (medical conditions placing Inﬂuenza (ﬂu) (people with medical conditions placing them at risk of serious complications of them at risk of serious complications of inﬂuenza) inﬂuenza) Pneumococcal conjugate (13vPCV) 12 months (medically at risk)e Pneumococcal polysaccharide (23vPPV) 4 years (medically at risk)e New Zealand national immunisation schedule (eﬀective from 1st January 2017#) 6 weeks Rotavirus (start ﬁrst dose before 15 weeks)—1 oral vaccine (RotaTeq®) Diphtheria/Tetanus/Pertussis/Polio/Hepatitis B/Haemophilus inﬂuenzae type b (INFANRIX®hexa) Pneumococcal (SYNFLORIX®) 3 months Rotavirus (RotaTeq®) Diphtheria/Tetanus/Pertussis/Polio/Hepatitis B/Haemophilus inﬂuenzae type b (INFANRIX®hexa) Pneumococcal (SYNFLORIX®) 5 months Rotavirus (RotaTeq®) Diphtheria/Tetanus/Pertussis/Polio/Hepatitis B/Haemophilus inﬂuenzae type b (INFANRIX®hexa) Pneumococcal (SYNFLORIX®) 15 months Haemophilus inﬂuenzae type b (Act-HIB) Measles/Mumps/Rubella (M-M-R® ll) Pneumococcal (SYNFLORIX®) Varicella (Varilrix®) 4 years Diphtheria/Tetanus/Pertussis/Polio (INFANRIX™-IPV) Measles/Mumps/Rubella (M-M-R® ll) 11–12 years Tetanus/Diphtheria/Pertussis—1 injection (BOOSTRIX™) Human Papillomavirus (HPV) 2 injections (Gardasil® 9) given at least 6 months apart for those aged 14 and under or 3 injections given over 6 months for those aged 15 and older a Hepatitis B vaccine: should be given to all infants as soon as practicable after birth. The greatest benefit is if given within 24 hours, and must be given within 7 days. b Rotavirus vaccine: third dose of vaccine is dependent on vaccine brand used. Contact your state or territory Health Department for details. c Hepatitis B and Varicella vaccine: contact your state or territory Health Department for details on the school grade eligible for vaccination. d HPV vaccine: is for all adolescents aged between 12 and 13 years. A catch-up program for males aged between 14 and 15 years was available until December 2014. Contact your state or territory Health Department for details on the school grade eligible for vaccination. e Pneumococcal vaccine: Medically at risk children require: a fourth dose of 13vPCV at 12 months of age; and a booster dose of 23vPPV at 4 years of age. Aboriginal and Torres Strait Islander children require a fourth dose of pneumococcal vaccine (13vPCV) at 12–18 months of age for children living in high risk areas (Queensland, Northern Territory, Western Australia and South Australia). Contact your state or territory Health Department for details. f Hepatitis A vaccine: two doses of Hepatitis A vaccine for Aboriginal and Torres Strait Islander children living in high risk areas (Queensland, Northern Territory, Western Australia and South Australia). Contact your state or territory Health Department for details. * © Commonwealth of Australia, www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-programschedule. # © Ministry of Health New Zealand, www.health.govt.nz/our-work/preventative-health-wellness/immunisation/new-zealand-immunisationschedule Family history and social history The family history will help determine whether familial or genetic disorders, such as asthma, diabetes, etc, are likely. Relationships between family members and the illnesses suﬀered can be documented on a family tree for clarity. In some circumstances it may also be important to note consanguinity between parents, as this increases the risk of genetic and familial disorders and is common in some communities. The health of siblings should also be explored as they may be a potential infectious contact or exhibit similar signs of familial or genetic disorders. A endance at childcare also increases the child's exposure to infectious diseases and it is important to note whether there has been a recent epidemic at the patient's childcare facility. Furthermore, childcare workers may also be able to contribute to the history. The child's living circumstances should also be considered, in particular to identify other risks to health such as cigare e smoke exposure, which increases the risk of respiratory diseases, meningococcal disease, Perthes’ disease, sudden infant death syndrome (SIDS), etc.9,10 In some circumstances, recent travel may be relevant to the current presentation. A complete history should identify who acts as the primary carer and whether there are others who play a signiﬁcant role as carer. Where a second person cares for the child for signiﬁcant periods of time, this person may be able to add substantially to the history. Additionally, consideration should be given to providing this person with similar healthcare information as is provided to the parents to ensure that they are well placed to care for the child's health. Child at risk Mandatory reporting legislation in all jurisdictions in Australia demands that healthcare professionals report suspicions that a child has suﬀered physical, emotional or sexual abuse to the statutory child protection authority in that jurisdiction A summary of the legislative duties can be found on the Australian Institute of Family Studies website.11 Child abuse is not common; however, healthcare professionals responsible for the care of children must consider the possibility and respond appropriately where their suspicions have been aroused, as child protection is of the highest priority. Clinicians should also be alert to signs of family violence as this has profound eﬀects on the wellbeing of the child. A detailed discussion of violence, abuse and assault is presented in Chapter 39. The most common concern identiﬁed by pre-hospital and ED clinicians relates to injuries where the cause is thought not to be the result of an accident. Suspicion should be aroused when there are inconsistencies in the history provided, the version of events changes over time, it is reported diﬀerently by each of the parents or does not adequately explain the presenting injuries. Less commonly, the presentation may be for an unrelated health problem and evidence of injury of potential abuse is uncovered, or the parent is disproportionately concerned about their child's condition and keen for the child to be admi ed, and exploration of the reason for this reveals their concern for their child's welfare while in their care. Care of the child where abuse is suspected should be handed over to a senior clinician and these suspicions raised. However, this does not abrogate responsibility for ensuring appropriate reporting occurs. Alternatively, the accompanying adult may acknowledge that there has been family services involvement with the family or this may be noted in the child's history. It is important to determine what responsibilities this places on the examining clinician; for example, reporting all injuries to state authorities, gaining consent from a state-appointed custodian, etc. Practice tips History Parents, siblings and the patient may provide key historical data. Mnemonics suited for infants and children, such as CIAMPEDS, may provide a useful guide for history-taking. Serious illness may be associated with non-speciﬁc signs and symptoms in infants, such as poor feeding, lethargy, irritability and poor sleeping. The perinatal history, immunisation status, infectious contact history, sibling and family history and childcare a endance frequently provide clues to the nature of the illness. Examination Physical examination of infants and young children and interpretation of the ﬁndings can be more diﬃcult, as they frequently become distressed and are uncooperative when touched. Examination techniques frequently require signiﬁcant adaptation and clinicians will need to rely more heavily on careful observation to elicit reliable examination data. Delaying the examination while you develop a rapport with ﬁrst the parents and then the child before a empting to examine a potentially uncooperative child is ideal. Using strategies to increase their conﬁdence and gain their cooperation was discussed in the previous section and is essential to make adequate examination possible. Allowing infants to remain in their parent's arms during the examination, making a game out of parts of the examination for toddlers and providing clear explanation to older children of what is intended are examples of strategies that may help increase a child's conﬁdence. Table 35.6 details some practical techniques for approaching infants and children of diﬀerent ages. TABLE 35.6 Age-specific approaches to physical examination during childhood12 POSITION Infant Best positioned on parent's lap, particularly for sections of the examination that are likely to be distressing Toddler Best positioned on parent's lap, particularly for sections of the examination that are likely to be distressing Preschool child Allow child to determine where they would like to sit—on parent's lap or on the trolley Ensure parents are close School-age child Cooperative in most positions Younger child prefers parent's presence Older child may prefer privacy Adolescent Same as for school-age child Oﬀer option of parent's presence SEQUENCE PREPARATION If quiet, auscultate heart, lungs, abdomen ﬁrst Palpate and percuss same areas Undress only when required to prevent babies ge ing cold Proceed in usual head-to-toe direction Perform traumatic procedures last (eyes, ears, mouth [while crying]) Clinician should sit on low chair in view of infant but out of reach while taking history, to allow infant to become more comfortable with clinician (older infant) Gain cooperation with distraction, bright objects, ra les, talking Smile at infant; use soft, gentle voice Pacify with feeding Enlist parent's aid for restraining to examine ears, mouth Avoid abrupt, jerky movements Take history ﬁrst, while observing infant and allowing them to watch Use minimum physical contact initially Inspect body area through play: ‘count ﬁngers’, ‘tickle toes’ Introduce equipment slowly Auscultate, percuss, palpate whenever quiet Examine injured limb last; start with the unaﬀected limb. Repeat to determine whether tenderness is reproducible Perform traumatic procedures last (same as for infant) Clinician should sit on low chair in view of child but out of reach while taking history, to allow child to become more comfortable with clinician Ask parent to undress child well before examination is a empted, to allow child to se le before a empting to examine Allow child to inspect equipment; demonstrating use of equipment is usually ineﬀective If uncooperative, perform procedures quickly Use restraint when appropriate; request parent's assistance Talk about examination if cooperative; use short phrases Praise for cooperative behaviour If cooperative, proceed in head-to-toe direction If uncooperative, proceed as with toddler Request self-undressing Allow to wear underpants if shy Oﬀer equipment for inspection; brieﬂy demonstrate use Make up story about procedure (e.g. ‘I'm seeing how strong your muscles are' [blood pressure]) Give choices when possible Expect cooperation; use positive statements (e.g. ‘Open your mouth’) Proceed in head-to-toe direction May examine genitalia last in older child Respect need for privacy. Expose only area to be examined Request self-undressing Explain purpose of equipment and signiﬁcance of procedure, such as otoscope to see eardrum, which is necessary for hearing Teach about body function and care Use simple language for explanations as they are easily frightened by misunderstood language Same as older school-age child Leave intrusive/embarrassing examinations until last Allow to undress in private and provide gown Expose only area to be examined Respect need for privacy Explain ﬁndings during examination: ‘Your muscles are ﬁrm and strong’ Emphasise normalcy of anatomy and development, including genitals Examine genitalia as any other body part; may leave to end Using a systematic approach to assessment ensures that priorities are addressed in order and that important features are not overlooked. However, when examining children it may be necessary to reorder the examination to move from least to most invasive. Assessment conducted as a primary and secondary survey is a common approach to emergency assessment and this can be applied to children. Identifying the physical diﬀerences between adults and children where they relate to each component of the survey ensures that these diﬀerences are accounted for, and that the results of assessment are appropriately interpreted considering these diﬀerences, while allowing the clinician to use one approach for all age groups. However, several other assessment tools have been designed speciﬁcally for use in children and include indicators shown to increase the recognition of serious illness in children. They will be discussed later in this section. The following sections will address the primary survey and the collection of vital signs, highlighting the signiﬁcance of immaturity. This discussion is supplemented by the details in Table 35.1. Airway Evaluation of the airway will concentrate on determining airway patency. A narrower airway and increased soft tissue places the infant and child at greater risk of airway obstruction, and stridor is a common paediatric presentation indicating airway obstruction. Other upper respiratory tract noises such as snore and stertor are also common, and can be the result of issues such as nasal congestion secondary to viral illness, enlarged tonsils, etc. Assessment of work of breathing, which is described in the next section, should make it possible to evaluate the extent of the airway obstruction. The pitch or loudness of upper respiratory noises should not be relied upon to assess severity of airway obstruction. Breathing Infants and children tolerate respiratory distress very poorly. It is the most common antecedent to paediatric cardiopulmonary arrest.13 The primary focus of respiratory assessment is an assessment of the work of breathing. Increased work of breathing has been shown to be an indicator of signiﬁcant or serious illness in infants.2,3,14 In addition, the work of breathing and mental state are considered the most useful indicators of the severity of asthma.15 Increased work of breathing is reliably recognised in infants and children by the presence of subcostal, suprasternal and intercostal recession (Fig. 35.1), the severity of which is deﬁned as mild, moderate and severe.16 FIGURE 35.1 Sites where recession may be visible on an infant. Other clinical ﬁndings, which will contribute to the assessment of the severity of respiratory dysfunction, are: respiratory rate oxygen saturations (SpO2) the presence or absence of nasal ﬂaring. Increasing respiratory rate suggests signiﬁcant illness. However, as infants and children become more exhausted, a drop in respiratory rate may signal deterioration. Rates over 50 breaths/minute in infants less than 2 months are predictive of hypoxia.17 However, it has also been shown that the respiratory rates of well infants under the age of 6 months vary considerably, from 20 to 80 breaths per minute.18 For these reasons, respiratory rate should be interpreted cautiously and not in isolation. Oxygen saturations support assessment of the eﬃcacy of breathing. Some evidence suggests that measurement of the SpO2 on presentation of infants and children with respiratory illness may assist in the prediction of those likely to require admission for respiratory observation and management.19,20 Finally, systemic signs, such as colour, heart rate and mentation, will also assist in determining respiratory adequacy. Hypoxia results in increasing pallor and, in extreme circumstances, cyanosis. Respiratory inadequacy results in an increasing heart rate, but infants are extremely susceptible to hypoxia and quickly respond with bradycardia. Similarly, increasing respiratory dysfunction results in deteriorating mental state and infants can progress from irritability to drowsiness very rapidly. Infants and young children use grunting to increase airway pressure and improve functional residual capacity and therefore oxygenation in respiratory illness. This involves closing of the glo is against expiration, resulting in positive-end expiratory pressure, which helps to prevent alveolar collapse. This creates the same eﬀect as pursed-lip breathing, often seen in older people with chronic lung disease. Grunting should alert the clinician to the presence of signiﬁcant pathology that has the potential to impact on oxygenation. Lung sounds contribute to diagnostic decision-making rather than an assessment of respiratory eﬃcacy. Wheezes are an expiratory noise reﬂecting narrowing of the airways. They are heard in several common paediatric illnesses, such as asthma and bronchiolitis, and in less common disorders, such as anaphylaxis and foreign-body inhalation. Other noises heard on auscultation are crackles, which may be widespread or localised. The small size of the chest and the thin chest wall can result in transmission of sounds across the lung ﬁelds and even from the upper airways, making it more diﬃcult to localise adventitious sounds. The infant or child presenting with respiratory illness and signiﬁcant distress should be monitored closely for signs of deterioration, evidenced by changes in work and eﬃcacy of breathing. Oxygen saturation and respiratory and heart rate monitoring are routinely used to provide continuous monitoring of these children. Circulation Assessment of circulatory function should rely on clinical ﬁndings, which will detect dehydration and hypovolaemia in the early stages. Even in the early stages before dehydration is severe enough to result in hypovolaemia, there is considerable overlap between the signs of each of these states. A empts have been made to identify the most sensitive and speciﬁc signs in children, with most studies focusing on dehydration. Simple measures are the most practical means to identify deﬁcits in infants and children, particularly pre-hospital and at triage. Skin colour, warmth and capillary reﬁll time (CRT) are all easily assessed without creating distress for the child. Sudden onset of pallor has been revealed by a series of studies as indicative of serious illness in infants.2,3 Capillary reﬁll time is considered an indicator of peripheral perfusion and therefore an indirect measure of cardiovascular function; 2 seconds is the accepted upper limit of normal.21 However, clinicians are cautioned about relying exclusively on this parameter, as the evidence for its sensitivity for detecting shock in young children is not convincing, with no correlation shown between delayed CRT and bacterial infection22,23 and no correlation shown between capillary reﬁll and invasive cardiovascular indices.24 Furthermore, the tools that show the highest levels of sensitivity and speciﬁcity for dehydration in gastroenteritis don't include capillary reﬁll time.25,26 It should also be noted that ambient temperature and the technique and site of measurement are also likely to aﬀect the sensitivity and speciﬁcity of the sign.27–30 The authors of a recent systematic review concluded that studies show that capillary reﬁll time shows reasonable speciﬁcity, but sensitivity is frequently poor.31 However, in the absence of more-suitable sensitive and speciﬁc non-invasive indices, CRT is still used for assessing peripheral perfusion and hydration for children pre-hospital and presenting to the ED. Hypovolaemia is evidenced by signs of poor end-organ perfusion and compensatory eﬀorts. Tachycardia (see Table 35.7 for normal values for age) and signs of vasoconstriction, such as skin pallor and mo ling, are two obvious signs of compensation aimed at improving cardiac output to secure adequate vital end-organ perfusion. As the child's condition worsens, the body initiates measures to overcome the derangements resulting from hypoperfusion, e.g. tachypnoea to reduce acidosis. However, as the capacity to compensate deteriorates, evidence of inadequate perfusion, such as hypotension and deteriorating conscious state, become apparent. TABLE 35.7 Average vital signs by age21 AGE GROUP Neonate Infant (1 month to 1 year) Toddler (1–2 years) Young child (2–7 years) Older child (7–12 years) PULSE RATE (beats/minute) 120–180 110–160 100–150 95–140 80–120 RESPIRATION RATE (breaths/minute) 40–60 30–40 25–35 25–30 20–25 BLOOD PRESSURE (systolic, mmHg) 60–80 70–90 80–95 90–110 100–120 Hypotension, deﬁned in children as a systolic blood pressure (SBP) lower than the 5th percentile for age (see Table 35.7 for normal values),32,33 occurs as a result of signiﬁcant hypovolaemia. However, in children it is a late sign, which is not apparent until approximately 30% of circulating volume is lost. There are limited data to support these values and they may even be slightly higher than the 5th percentile. However, in the absence of convincing data it is clinically rational to accept a higher threshold for the unwell child. Measuring a child's blood pressure provides practical challenges, which may aﬀect the accuracy of the result.34 Young children are frequently uncooperative, are often anxious and distressed and variation in their size aﬀects cuﬀ selection. A cuﬀ most closely representing 40% of the circumference of the upper arm gives a measurement closest to invasive radial blood pressure values.35 In some circumstances the cuﬀ is applied around the calf. However, there are no data to determine the correlation between this measurement and arterial blood pressure measurements. As hypotension is an indicator of poor prognosis, blood pressure measurements should be recorded regularly for infants and children at risk of cardiac dysfunction and/or hypovolaemia. However, treatment decisions should not rest solely on this parameter, particularly where the blood pressure is considered normal. The results should be considered in light of other cardiovascular ﬁndings.36 Reduced urine output is initially a mechanism to conserve ﬂuid. However, as hypovolaemia progresses, renal perfusion deteriorates and urine output decreases further. The minimum permissible urine output for infants (2 mL/kg/h) and children (1 mL/kg/h) is much higher than the minimum volume accepted for adults (0.5 mL/kg/h).21,36 Direct measurement of urine output in infants and children not yet toilet-trained is invasive and distressing to infants and children. To avoid catheterisation, which is common practice in adults to measure urine output, nappies are often weighed to provide an estimate of urine output. However, it has been shown that this is not an accurate measure and should not be used where the accuracy of the ﬂuid balance assessment is critical.37 In summary, signiﬁcant and potentially life-threatening hypovolaemia is characterised by a combination of signs, such as tachycardia, prolonged CRT, hypotension, tachypnoea, altered conscious state, decreased urine output and metabolic acidosis.38 Disability Conscious-state deterioration is a signiﬁcant indicator of poor prognosis, and alteration in the level of activity has been shown to be an indicator of serious illness in children.2 Decreased conscious state results from intracerebral pathology such as trauma and infection, but may also be an indication of inadequate oxygenation or circulation or other metabolic derangements. Children may manifest worrying changes in neurological status, such as lethargy, irritability, drowsiness, decreased activity and social interaction, including eye contact, and hypotonic posturing (extended limbs and abducted hips) with a broad array of illnesses. Clinicians should be wary of the child who appears disproportionately miserable or lethargic with minor illness. The variable developmental levels of children complicate neurological assessment and application of the Glasgow Coma Scale (GCS), a validated tool developed to standardise and quantify neurological assessment in adults. The GCS has been modiﬁed for use in children and is shown to compare favourably with the standard GCS for assessment of traumatic brain injury in older children.39 The modiﬁed GCS is presented in Table 35.8. The Advanced Paediatric Life Support course introduces a simpler alternative as a crude way of deﬁning conscious state in children, and this scale (AVPU) is presented in Box 35.1.21 The AVPU scale describes four levels of consciousness from alert to unconscious. It is generally accepted that ‘P’ (responds to painful stimuli) equates to a GCS score of 8. Finally, the value of parents and their capacity to identify deviations from normal in their child's level of function should not be underestimated. TABLE 35.8 The modified Glasgow Coma Scale for children40–42 AREA ASSESSED INFANTS Eye opening Open spontaneously Open in response to verbal stimuli Open in response to pain only No response Verbal response Coos and babbles Irritable cries Cries in response to pain Moans in response to pain No response Motor response Moves spontaneously and purposefully Withdraws to touch Withdraws in response to pain Responds to pain with decorticate posturing (abnormal ﬂexion) Responds to pain with decerebrate posturing (abnormal extension) No response CHILDREN Open spontaneously Open in response to verbal stimuli Open in response to pain only No response Oriented, appropriate Confused Inappropriate words Incomprehensible words or nonspeciﬁc sounds No response Obeys commands Localises painful stimulus Withdraws in response to pain Responds to pain with ﬂexion Responds to pain with extension No response SCORE* 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1 a A score is given in each category. The individual scores are then added to give a total score of 3 to 15. A score of < 8 is indicative of severe neurological injury. Box 35.1 AVPU scale 2 1 Alert Responds to Voice Responds to Pain only Unresponsive A fontanelle is the intersection where three/four cranial bones met and create a small gap between the bones. The anterior and posterior fontanelles are palpable until, on average, 3 and 18 months of age respectively, at which time they generally close. The anterior fontanelle is the one most commonly described and palpated during an examination. Palpation of the tension of the fontanelle allows for a gross estimate of intracranial pressure (ICP; tense and bulging indicates raised ICP) or hydration status (depressed/shrunken indicates dehydration). There are limited data to support the sensitivity and speciﬁcity of these ﬁndings. In a study to determine the signiﬁcance of a bulging fontanelle, 36% were associated with clinically signiﬁcant abnormalities.43 However, no a empt was made to determine the rate of abnormalities in infants without a bulging fontanelle. Fontanelle assessment ﬁndings should be considered in light of other ﬁndings and not in isolation. Pain assessment should also be included in neurological assessment, as pain may cloud capacity for accurate assessment and interpretation of other examination ﬁndings, particularly in children.44 Pain assessment is discussed further in Chapter 18 and in the sections on pain management and procedural sedation in this chapter. Vital signs Vital signs (respiratory rate, heart rate, temperature, blood pressure and oxygen saturations) and other appropriately-focused assessment parameters such as GCS, neurovascular observations, pain scores and blood glucose measurements should be recorded to provide a baseline (see Chapter 16 for information on blood glucose level sampling techniques). Values vary with age, making recognition of deviations from normal dependent on recognising normal values for the age of the child, which are presented in Table 35.7. The regularity with which these parameters are then measured will depend on the nature and severity of the illness and the treatment implemented. However, it should be recognised that the value of these parameters is usually in establishing trend data created by repeat measures, as single observations may be inﬂuenced by factors other than clinical deterioration or improvement, such as crying, sleeping, pain, etc. Heart rate measurement in infants and young children should involve palpation of the pulse to provide other information in addition to the rate, such as strength. In infants where the carotid pulse may be diﬃcult to locate due to their short neck, the brachial and femoral pulses provide a good alternative. Respiratory rate is most easily assessed during auscultation but may be aﬀected by a change in respiratory pa ern brought about by the child's awareness of being observed. Infrared tympanic thermometers (ITTs) have become the standard tool for temperature measurement for adults and children in the ED. However, there is some concern about their accuracy, particularly in infants and young children. The authors of two 2014 systematic reviews concluded that available evidence does not currently support infrared thermometers for accurate and consistent temperature measurement but that further study is warranted.45,46 An oral temperature measurement, aﬀected by hyperventilation, probe position and ingestion of hot or cold liquids, is also subject to inaccuracy and is not practical in infants and young children. Axillary temperature measurement has been advocated as a good alternative. However, studies have shown that this can be aﬀected by ambient temperature and changes in skin perfusion;47,48 measurements are on average likely to be from 0.4 (at low temperatures) to 1.0 degree (at temperatures over 39.0 degrees) lower than the oral or rectal temperature,49 in contrast to tympanic and oral temperature measurements, which were shown not to be inﬂuenced by ambient temperature.50 The clinically rational approach is to avoid tympanic thermometers in young babies where the ear canal is not large enough to allow insertion of the probe, and to view a normal temperature reading in this age group with caution, regardless of the measurement technique. It is well recognised that septic infants may present as hypopyrexic rather than hyperpyrexic.32 Weight In paediatric emergency care, the weight of the infant and child should be measured to provide important assessment data. Fluid loss is most accurately detected by repeat weight measurements, and infants and children with actual or potential for dehydration should be weighed 6-hourly during their hospital admission. Weight is also measured to guide medication dosing and ﬂuid volume calculations. For infants and children too unwell to weigh, this must be estimated. On average, newborns weigh approximately 3.5 kg and reach approximately 10 kg by one year of age, having gained an average of 200 g weekly for the ﬁrst few months of life followed by 100 g per week. There is increasing evidence that traditional formulae such as (Age + 4) × 251 may underestimate the weight of the majority of Australian children and for this reason Australian Paediatric Life Support Australasia has recently provided a new method for calculating weight, which can be seen in Table 35.11.21 It should be noted that the weight estimates are likely to underestimate the weight of overweight children. However, it is more appropriate to base medication doses on lean body weight making this inaccuracy unlikely to be clinically concerning. This also means that on some occasions it may be more appropriate to use an estimated weight based on age and height for markedly overweight children to prevent signiﬁcant overdose. Practice tips Examination The severity of airway obstruction is best assessed by determining the severity of the respiratory distress. Stridor intensity is not a useful indicator of the severity of airway obstruction. Work of breathing and mental state are the most useful indicators of the severity of respiratory distress. Respiratory noises reﬂect the underlying pathology, e.g. stridor is an upper airway noise and wheeze is a lower airway noise. Hypotension is a very late sign of hypovolaemia in infants and children. Capillary reﬁll measurement is a useful adjunct to assessment but should not be used as a single indirect measure of peripheral perfusion. All infants and children with an actual or potential ﬂuid and electrolyte imbalance should be weighed naked, as weight changes are the gold-standard measure for changes in ﬂuid balance. A modiﬁed Glasgow Coma Scale score for infants and children is recommended for assessment and documentation of neurological assessments. A single set of vital signs may be diﬃcult to interpret. Regular observations should be made to generate trend data, which is likely to be more useful. Age will inﬂuence the interpretation of diagnostic images and some pathology results. Diagnostic testing Diagnostic testing is employed to diagnose, exclude or identify the severity of disease, guide treatment options or determine the success of treatment. It is often invasive and distressing. Infants and children will require a combination of procedural sedation, local anaesthetic and analgesic, or in some cases a general anaesthetic for many diagnostic procedures, increasing the potential risks to the child. Therefore, it is important to be clear about what questions will be answered by the test results and whether answers to these questions are an important part of establishing a diagnosis or selecting management strategies. The signiﬁcance of age will also need to be considered when employing many sampling and imaging techniques and when interpreting test results. Diagnostic imaging Diagnostic images reveal anatomical diﬀerences that exist between infants, children and adults, and this inﬂuences interpretation of many images, including chest and skeletal X-rays. For example, the shape of the ribs, the relative size and shape of the heart, the relatively ﬂa ened diaphragms and the presence in infants of a prominent thymus distorting the mediastinum will all impact on what constitutes a normal chest X-ray. Skeletal immaturity is evident on skeletal X-ray with the presence of secondary ossiﬁcation centres and growth plates and a higher proportion of cartilage in the bones of children, all of which inﬂuence interpretation. Radiation safety is of concern for growing infants and children, and a empts are made to reduce their exposure wherever possible. There are decision rules, such as the O owa ankle rules (see Chapter 17) and a number of clinical decision rules for computed tomography (CT) in head injury,52 validated for use in paediatrics to assist the clinician in determining whether diagnostic imaging is required. Pathology Diagnosis of illness in infants and children is less frequently dependent on pathology testing than it is for adults. Furthermore, paediatric presentations are less commonly complicated by co-morbid disease, reducing the need for baseline evaluation of a range of measures of their underlying disease states. The range of tests taken, methods for obtaining specimens and interpretation of the results are dependent on the presenting problem and the age of the patient. Smaller blood vessels and larger amounts of subcutaneous tissue make gaining intravascular access for blood sampling particularly diﬃcult. Chapter 16 contains information on vascular access and catheter selection for all ages, and a section on paediatric considerations. It can also be diﬃcult to aspirate large volumes of blood for testing, so laboratories capable of handling paediatric samples can perform these tests on much smaller samples collected in paediatric-sized blood tubes. It is important to conﬁrm with the laboratory their capacity to test small samples before taking blood. Capillary samples from ﬁnger pricks are sometimes used as an alternative where intravenous access and larger volumes of blood are not required. Urine specimens for microbiology and culture should be obtained from infants and young children not yet toilet-trained by urethral catheterisation or suprapubic aspirate. Urine bags applied to the skin to catch a urine specimen are not a satisfactory means to collect urine for this purpose as they are frequently contaminated.53 The reference ranges for some common pathology screening tests vary with age, and this must be considered when interpreting the results: haemoglobin, serum albumin, protein (CSF) base excess, serum creatinine, erythrocyte sedimentation rate (ESR), red blood cell (RBC) count, serum potassium, etc. Furthermore, diﬀerent laboratories use diﬀerent ranges. Therefore, the reference ranges should be checked with the laboratory testing the samples. Triage Triage is the process used by emergency care clinicians to determine the urgency of the patient's presenting problem and allocate resources appropriate for the level of urgency of their condition. Paediatric triage assessment and decision-making, similar to adult triage practice, relies on recognising breaches to physiology which indicate the level of urgency.54 Triage has been formalised in the ED, but the principles applied by pre-hospital clinicians to determine urgency triage category allocation for children must be based on the level of urgency of the presenting problem while considering the inﬂuence of age-related factors. Triage is discussed more extensively in Chapter 11. Australasian EDs use the Australasian Triage Scale (formerly the National Triage Scale in Australia). Studies have repeatedly demonstrated that there is some inconsistency in the application of this scale and that the level of inconsistency may be slightly higher for paediatric triage decisions.55–58 Infants and children are frequently allocated higher categories than adults with similar presentations.44,59 Although this is now old data there is no reason to consider that this is not still the case. Guidelines recommending a standardised approach based on age are often used to ensure the safety of infants and young children who may present with unrecognised serious illness. However, allocation of a higher acuity category to all infants and young children will result in many children receiving higher categories than their condition dictates, while signiﬁcantly disadvantaging other, sicker patients in greater need of urgent care. These guidelines should be viewed cautiously as they corrupt the primary purpose of triage.54 It has been suggested that inconsistency in education contributes to inconsistency in decisionmaking,60 and yet historically the experience and education of triage nurses in Australia varies greatly.61,62 Similar inconsistencies existed in the preparation of nurses for undertaking paediatric triage decision-making in Australian EDs.63 In an a empt to address this, the Australian Commonwealth government has invested in triage education by sponsoring the development of the Emergency Triage Education Kit (ETEK), which includes a section on paediatric triage. The importance of including paediatric-speciﬁc education in triage training programs has long been recognised nationally and internationally.64–71 Triage nurses must consistently and accurately identify the child requiring more-urgent a ention based on the risk of mortality and morbidity, which is determined by historical data and clinical presentation and not age alone. This principle is supported by the Australasian College for Emergency Medicine, which states that ‘the same standards for triage categorisation should apply to all ED se ings’; ‘all 5 categories should be used in all se ings’; and that ‘children should be triaged according to objective clinical urgency’.72 Triage assessment Urgency rather than seriousness or severity of illness or injury is the foundation of the triage decision. However, appropriate triage category allocation is not possible without the recognition of the clinical features of serious illness and actual or potential deterioration, and recognition of serious illness is acknowledged as diﬃcult in young children. A number of clinical features have been found either positively or negatively predictive of serious illness in young children; these have been discussed previously in this chapter and should be considered when determining urgency. It has been repeatedly shown that physiological derangements are the antecedent to deterioration and adverse outcomes, and this has also been demonstrated to be the case for children.73–75 Therefore, a framework to guide triage assessment and decision-making has been developed which focuses on physiological parameters.73,76 This was originally developed for use with adults, with a second tool for paediatrics developed at a later date. The physiological approach directs the clinician to undertake a primary survey and therefore consider the following: the general appearance of the patient, airway, breathing, circulation and disability.54 This assessment is supplemented with a relevant, focused secondary survey. A brief history is taken to identify from the chief complaint, past history, family and social history risk factors for rapid deterioration in condition. Identiﬁed risks should be considered in light of the physiological data collected and may result in revision of the urgency assessment.54 The physiological approach to decision-making was developed by the Emergency Nurses Association, Victoria and was modiﬁed for paediatrics by the project team for the Department of Health, Victoria sponsored ‘Consistency in Triage Project’.73 The framework is presented in Table 35.9. TABLE 35.9 Paediatric physiological discriminators developed for the Australasian (National) Triage Scale73 CATEGORY 1 Obstructed Partially obstructed with severe respiratory distress Breathing Absent respiration or hypoventilation Severe respiratory distress, e.g. severe use of accessory muscles, severe retraction, acute cyanosis Circulation Absent circulation S/S Signiﬁcant dehydration: bradycardia, e.g. HR ↓ LOC/activity < 60 bpm in an Capillary reﬁll < infant 2s Severe Dry oral haemodynamic mucosa compromise, e.g Sunken eyes absent peripheral ↓ tissue turgor pulses skin pale, Absent tears cold, moist, mo led Deep signiﬁcant respirations tachycardia Thready/weak capillary reﬁll > 4 s pulse Uncontrolled Tachycardia haemorrhage ↓ urine output Mental health Deﬁnite danger to life (self or others), emergencies83 (used e.g. with permission violent behaviour from South Eastern possession of a Sydney Area Health weapon Service) self-destruction Airway CATEGORY 2 Patent Partially obstructed with moderate respiratory distress Respiration present Moderate respiratory distress, e.g. moderate use of accessory muscles, moderate retraction, skin pale Circulation present Moderate haemodynamic compromise, e.g. weak/thready brachial pulse, skin pale, cool moderate tachycardia capillary reﬁll 2–4 s > 6 S/S dehydration Probable danger to life (self or others), e.g. a empt/threat of self harm, threat of harm to others Severe behavioural disturbance, e.g. extreme agitation/restlessness, physically/verbally aggressive, confused/unable to cooperate Requires restraint CATEGORY 3 Patent Partially obstructed with mild respiratory distress Respiration present Mild respiratory distress, e.g. mild use of accessory muscles, mild retraction, skin pink Circulation present Mild haemodynamic compromise, e.g. palpable peripheral pulses skin pale, warm mild tachycardia 3–6 S/S dehydration CATEGORY 4 Patent CATEGORY 5 Patent Respiration present Respiration present No respiratory distress: no use of accessory muscles no retraction Circulation present No haemodynamic compromise, e.g. palpable peripheral pulses, skin pink, warm, dry < 3 S/S dehydration Possible danger to Moderate distress, life, e.g. e.g. suicidal ideation no Severe distress agitation/restlessness Moderate irritable, not behavioural aggressive disturbance, e.g. cooperative agitated/restless gives coherent intrusive history behaviour symptoms of anxiety bizarre/disordered or depression behaviour without suicidal withdrawn ideation ambivalence re treatment Psychotic symptoms, e.g. hallucinations delusions, paranoid ideas Aﬀective disturbance, e.g. symptoms of depression anxiety elevated or irritable mood Ophthalmic Penetrating eye Sudden abnormal Normal vision emergencies injury vision with or Mild eye pain, e.g. Chemical injury without injury blunt eye injury Sudden loss of vision Moderate eye ﬂash burns with or without pain, e.g. foreign body injury blunt eye injury Sudden-onset severe ﬂash burns eye pain foreign body Risk factors for serious illness or injury should be considered in the light of history of events and physiological data. Multiple risk factors = increased risk of serious injury Presence of one or more risk factors may result in allocation of triage category of higher acuity. No respiratory dis no use of accessory Circulation present No haemodynami palpable periphera skin pink, warm, d No S/S dehydration No danger to self o No behavioural di No acute distress, cooperative communicative compliant with ins known patients wi request for medica minor adverse eﬀe ﬁnancial/social/acc problem Normal vision No eye pain Mechanism of injury, e.g. penetrating injury fall > 2 × height MCA > 60 kph MBA/cyclist > 30 kph pedestrian ejection/rollover prolonged extrication (> 30 minutes) death of samecar occupant explosion CATEGORY 1 CATEGORY 2 Co-morbidities, e.g. Age < 1 month and: history of febrile prematurity acute change to respiratory disease feeding pa ern cardiovascular acute change to disease sleeping pa ern renal disease Victim of violence, carcinoma e.g. diabetes child at risk substance abuse sexual assault immunocompromise neglect congenital disease complex medical Hx CATEGORY 3 Historical variables, for example events preceding presentation to ED: apnoeic/cyanotic episode seizure activity decreased intake decreased output redcurrant-jelly stool bile-stained vomiting Parental concern CATEGORY 4 CATEGORY 5 Other, e.g. rash actual/potential eﬀects of drugs/alcohol chemical exposure envenomation immersion alteration in body temperature bpm: beats/minute; HR: heart rate; LOC: loss of consciousness; MBA: motorbike accident; MCA: motor car accident; S/S: signs and symptoms The principles of paediatric triage, the assessment framework and triage priorities are no diﬀerent from those applied to adults. Identiﬁcation of the physical, cognitive and developmental diﬀerences that exist between children and adults ensures that appropriate adjustments to assessment can be made and that assessment ﬁndings are appropriately interpreted in light of these diﬀerences.21 Assessment tools The value to paediatric assessment of evidence-based indicators of serious illness in infants and children has culminated in the development of several assessment tools.2,77–82 The focus of these tools is a combination of historical details and easily observable physical ﬁndings that increase the likelihood of detecting serious illness in infants and children and there are obvious similarities between them. Although none of the available tools can direct category allocation, these tools prompt assessment, thereby guiding triage decision-making. Their role is to reinforce the features that should alert the triage nurse to the increased likelihood of serious illness.54 The ‘ABC, ﬂuids in, ﬂuids out’ tool reﬂects the presenting characteristics of infants in a cohort of over 1000 babies found to have serious illness.83 A subsequent validation study demonstrated that this tool, with the addition of urine screening for infection, has the capacity to identify 90% of seriously ill infants. The Triage Observation Tool (TOT) prompts the triage nurse to examine the clinical features listed in this tool. Despite the tool not oﬀering a guide for triage decision-making on the basis of assessment ﬁndings, use of the TOT improved the correlation between admission rates and triage category.78 The Pediatric Assessment Tool was designed to standardise the rapid assessment of infants and children by ED clinicians.81 Clinicians are prompted to review the work of breathing, circulation to the skin and the appearance of the child to determine whether the child ‘looks sick’ or not, and to broadly identify whether this reﬂects cardiopulmonary, cerebral or metabolic derangement. The TICLS (tone, interactivity, consolability, look/gaze and speech/cry) mnemonic provides additional guidance to clinicians unfamiliar with evaluating the appearance of infants and children.84 The Paediatric Observation Priority Score (POPS) is a scoring system for children aged 0–16 years based on physiological, behavioural and risk parameters,82 which assists clinicians to assess and prioritise the needs of the child or infant and has been shown to correctly identify 85% of children safe for discharge from hospital. Descriptions of several of these tools can be found in Table 35.10. TABLE 35.10 Paediatric assessment tools TOOL ABC, ﬂuids in, ﬂuids out87 Triage Observation Tool (TOT)82 ASSESSMENT CRITERIA Activity Breathing Circulation Fluids in Fluids out Ask Activity Feeding Dehydration Gastrointestinal Risk factors Listen Cry Breathing Look/feel Eye contact Ventilation Skin Circulation Consciousness Dehydration Vital signs Temperature Respiratory rate Heart rate Blood pressure Oxygen saturation EXPLANATION Reduced activity or lethargy is a signiﬁcant ﬁnding Increased work of breathing Sudden onset of pallor is a signiﬁcant ﬁnding Less than two-thirds of normal intake suggests serious illness Less than two-thirds of normal output suggests serious illness Irritable, drowsy, hard to wake, not reacting to caregiver > 50% reduction, fatigues, sweating, change in routine Sunken eyes, reduced urine output, dry oral mucosa > 5 vomits in 24 hours, vomiting bile, > 5 watery stools in 24 hours Immune deﬁciency, steroids, chronic/underlying disease, neonate Persistent, weak, high-pitched, inconsolable Stridor, wheeze, grunting, rapid rate, irregular No eye contact, glassy stare, unresponsive to visual stimuli Nasal ﬂaring, tracheal tug, sternal recession, fatigued Rash, mo led, pallor, cyanosis Reduced capillary return, hypotension/‘shut-down’ Lethargic, rousable to pain, unresponsive, abnormal movement Dry oral mucosa, sunken eyes, reduced urine output < 35.5°C > 38.5°C (using tympanometer) Hypoventilation, tachypnoea Bradycardia, tachycardia Decreased pulse pressure, hypo- or hypertension < 93% Practice tips Triage Allocate a triage category based on the level of urgency of the infant's or child's presenting problem. The physiological approach to triage is recommended for paediatric triage decision-making. Avoid standardised approaches to triage category allo-cation for infants and children, which may improve the safety of the child but dilute the value of triage and result in delays for other potentially sicker adult patients. Respiratory emergencies Respiratory failure Respiratory failure can be deﬁned as the inability of the respiratory system to maintain adequate oxygenation and carbon dioxide homeostasis to meet metabolic demand. Broadly, respiratory failure can be seen as a result of inadequate ventilation or oxygenation or a combination of the two. Respiratory failure is often deﬁned by arterial partial pressure of oxygen (PaO2) and of carbon dioxide (PaCO2), with arbitrary limits set. However, these values should only guide clinical decision-making and should not solely deﬁne the diagnosis as their signiﬁcance will be inﬂuenced by pre-existing illness and age. For a comprehensive discussion about the physiology of respiratory failure, see Chapter 21. Disorders of the respiratory tract are the most common illnesses in children. They account for up to 14% of hospital admissions and a quarter of ED presentations in Australia.85,86 The majority of these illnesses are mild and can be safely managed at home. However, a small number of infants and children experience severe respiratory distress, which may lead to respiratory failure. There are age-related factors that make infants and young children more susceptible to respiratory failure than older children and adults. Table 35.1 provides a comprehensive list of the respiratory diﬀerences between infants, young children and adults. Oxygen consumption is much higher in infants and young children than it is in adults, which helps explain a signiﬁcantly higher minute volume in this age group. Tidal volume (mL/kg) is relatively ﬁxed, and increased alveolar ventilation is achieved by an increase in respiratory rate. However, the capacity to increase the respiratory rate to meet metabolic demands can be exhausted quickly in the sick or injured infant, predisposing them to respiratory failure. Therefore, a falling respiratory rate is not always a sign of improvement but may be a pre-terminal ﬁnding. Infants and children also have a lower functional residual capacity (FRC), which is deﬁned as the residual volume plus the expiratory reserve volume, which acts as a respiratory reserve. At FRC, the elastic recoil forces of the lungs and the chest wall are equal but opposite and there is no exertion by the diaphragm or other respiratory muscles. The smaller the FRC, the smaller the reserve and the greater the risk of hypoxia and respiratory failure. The situation is ampliﬁed in paediatric patients because of the chest-wall compliance, small thoracic cage and relatively large abdominal contents impinging on the diaphragm.21,87 The more compliant chest wall of the infant provides li le support to the lungs. In addition to the eﬀect that this has on FRC, increased chest-wall compliance makes it more diﬃcult to maintain negative intrathoracic pressure, so the work of breathing is approximately three times that of an adult. However, the respiratory muscles of infants and young children are deﬁcient in type I fatigue-resistant ﬁbres and are therefore more susceptible to fatigue.87 Infants and young children have limited reserves to cope with respiratory illness and deteriorate rapidly once exhausted. Control of ventilation is immature in neonates and responses to hypoxic conditions are unpredictable and sometimes result in periods of apnoea. Presentation Respiratory assessment has been described in an earlier section of this chapter. Infants and children in respiratory failure present with varying degrees of hypoxia and hypercarbia. The infant and young child with hypoxia will become increasingly restless and confused and will initially be tachycardic. Infants are particularly sensitive to hypoxia and rapidly become bradycardic if left untreated. Infants and young children suﬀering hypercarbia will become increasingly drowsy, have warm, ﬂushed diaphoretic skin and are tachycardic. Neonates tolerate hypercarbia poorly and may suﬀer apnoea as a result. Respiratory failure is a clinical diagnosis, which obviates the need for arterial blood gas (ABG) analysis to make the diagnosis and conﬁrm the need for aggressive respiratory care. However, insertion of an arterial line for serial ABG analysis is justiﬁed in a child with severe respiratory illness receiving ventilatory support to monitor the eﬀectiveness of treatments. Management Management of respiratory failure aims to improve ventilation, oxygenation or both. Furthermore, care should include strategies to minimise oxygen consumption such as: keeping children as calm as possible, using the parents to reduce their distress and employing appropriate distraction techniques. Antipyretics may also play a role to reduce the metabolic costs associated with fever. Strategies to improve ventilation include bronchodilators, intubation and mechanical ventilation, while strategies to improve oxygenation include oxygen therapy, non-invasive ventilation to provide continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) and intubation and mechanical ventilation to provide positive end-expiratory pressure (PEEP). Oxygen therapy and mechanical ventilation will be discussed here. Oxygen therapy Oxygen therapy is the mainstay of respiratory management, and yet data detailing the eﬀectiveness of therapy or the appropriateness of diﬀerent delivery systems are limited. A recent Cochrane review, which aimed to determine the eﬀectiveness of oxygen therapy and delivery methods in children, found no studies comparing oxygen with no oxygen, and only four randomised controlled trials evaluating delivery devices.88 Nasal prongs or nasal cannulae, nasal catheters, oxygen tents and hoods and face masks are the methods used to deliver oxygen to spontaneously breathing infants and children. The choice of device is inﬂuenced by the age of the child, the oxygen ﬂow required and the advantages and disadvantages of the available delivery systems. Ideally, oxygen is humidiﬁed. However, during pre-hospital transport and initial evaluation and resuscitation in the ED this may not be possible and should not be a priority. The face mask is a simple device commonly used to deliver high-ﬂow oxygen. Paediatric-size

Paediatric Emergencies PDF

Document Details

Tags

Related

Summary

Full Transcript

Upgrade to continue