Acutely Unwell Child

Jay Shetty

Clinical Lecturer in Child Health

Unwell Child

• Different Physiology, anatomy and aetiology compared to adults.

• Approach for resuscitation and treatment are different

• Common causes of acute illness in children

Aetiology of Cardiac Arrest in Children

Respiratory Obstruction

Respiratory Depression

Fluid Maldistribution

Fluid Loss

Foreign BodyAsthmaCroup

Convulsions Poisoning

Raised ICP

SepsisAnaphylaxis

Cardiac Failure

Blood Loss Burns

Vomiting

Cardiac Arrest

Respiratory Failure Circulatory Failure

Age [Years]

Heart Rate

Respiratory rate

Systolic Blood Pressure [mmHg]

<1 110-160 30-40 70-90

1-2 100-150 25-35 80-95

2-5 95-140 25-30 80-100

5-12 80-120 20-25 90-110

>12 60-100 15-20 100-120

Systematic Approach

• Airway

• Breathing

• Circulation

• Disability

• Exposure

Potential Respiratory Failure

• Effort

• Effect• Efficacy

Effort of Breathing

• Recession• Respiratory rate• Accessory muscle use• Nasal flare• Child’s position• Sounds

– Inspiratory stridor– Expiratory wheeze– Grunting

Efficacy of Breathing

• Chest Expansion

• Air Entry

• Saturations

Effects of Breathing

• Heart Rate

• Skin Colour

• Mental Status

Potential Circulatory Failure

Early Recognition of Shock

• Cardiovascular Signs

• Effects of Circulatory Inadequacy

Circulatory Signs

• Pulse Rate• Pulse Volume• Capillary Refill• Blood Pressure

Hypotension is a pre-terminal sign

Effects of Circulatory Inadequacy

• Respiratory Rate

• Skin Temperature/Colour

• Mental Status

Potential Central Neurological Failure

• Conscious Level

• Pupils

• Posture

Conscious Level

• Alert

• Responds to Voice

• Responds only to Pain

• Unresponsive to all stimuli

• AVPU

Posture

• Alert

• Decorticate/Decerebrate Posturing

Summary – Rapid Assessment

• Airway and Breathing• Effort• Efficacy• Effects

• Circulation• Heart Rate• Capillary Refill Time• Blood Pressure• Skin Temperature

• Disability• Conscious Level• Posture• Pupils

Common Causes

• Systemic Infection/Sepsis.

• Trauma/Burns/Overdose

• CNS: Meningitis, Encephalitis, Seizures.

• Respiratory: Pneumonia, Bronchiolitis, Asthma, Croup, Tracheitis, Epiglottitis.

• Cardiovascular: Congenital heart disease, arrhythmias

Common Causes

• GI: Gastroenteritis, bowel obstruction, Appendicitis, Malrotation.

• Urogenital: UTI, Epididemo-orchitis, testicular torsion.

• Haematological: Acute leukaemia, Anaemia.• Musculoskeletal: Osteomyelitis, Reactive arthritis• Others: Metabolic disorders, Allergy and

anaphylaxis, Intoxication, Nonaccidental Injury.

Infection/Sepsis

• Commonest cause for acute illness in children

• Varying presentation [rash, fever, poor feeding, lethargy, system specific symptoms]

• Treatment: supportive and antimicrobial

Trauma

• RTA

• Trampoline, sports injuries

• Type: Fractures, Head injury, abdominal injuries.

• Initial approach to management is BLS with Cervical spine immobilisation.

• Burns and overdose (?NAI)

CNS

• Meningitis: Bacterial and viral

• Encephalitis: Commonly viral

• Presentations and findings vary at different age groups

• Investigation includes lumbar puncture and imaging.

• Supportive and Specific treatment

Fits, Faints and Funny turns

• Febrile seizures

• Epileptic attack, Status epilepticus

• Vasovagal episode, Reflex anoxic seizures

• Breath holding attacks

• Behavioural episodes

• Arrhythmias

CVS

• Cyanotic Heart disease present early in life

• Bacterial endocarditis is a severe infection

• Heart murmurs

• Arrhythmias are rare in children, Supraventricular tachycardia is the commonest.

GI/Urogenital

• Viral gastroenteritis is a common illness and can lead to severe dehydration.

• Congenital pyloric stenosis, Volvulus, Intussusceptions and malrotation are common causes of GI obstructions in children

• Appendicitis is the most common acute abdominal condition

• UTI’s are common in children

Common Causes

• Systemic Infection/Sepsis.

• Trauma/Burns/Overdose

• CNS: Meningitis, Encephalitis, Seizures.

• Respiratory: Pneumonia, Bronchiolitis, Asthma, Croup, Tracheitis, Epiglottitis.

• Cardiovascular: Congenital heart disease, arrhythmias

Common Causes

• GI: Gastroenteritis, bowel obstruction, Appendicitis, Malrotation, Hepatitis.

• Urogenital: UTI, Epididemo-orchitis, testicular torsion.

• Haematological: Acute leukaemia, Anaemia.• Musculoskeletal: Osteomyelitis, Reactive arthritis• Others: Metabolic disorders, Allergy and

anaphylaxis, Intoxication, Nonaccidental Injury.

Shock

• Inadequate tissue perfusion resulting in impaired cellular respiration -inadequate supply of nutrients to tissues -inadequate removal of tissue wastes

• Failure of circulatory function [Heart, Blood, Blood vessels]

Shock

• Cardiogenic [arrhythmia, cardiomyopathy, valvular heart disease, contusion]

• Hypovolemic [ haemorrhage, GE, gut obstruction, Burns, Peritonitis]

• Distributive [Sepsis, Anaphylaxis, Drugs]

• Obstructive [Pneumothorax, tamponade ]

• Dissociative [Anaemia, CO poisoning]