ASSESSING SEVERITY OF ILLNESS IN THE CHILD

By Dr. Derek Louey

ASSESSING SEVERITY OF ILLNESS• Applies particularly to

neonates/infants/toddlers

• Don’t be intimidated

• Follow a systematic approach

• Assess severity first - diagnosis comes later

ASSESSING SEVERITY OF ILLNESS• Initial assessment

• Occurs without needing to touch the child• Can be performed rapidly in less than 1 minute• Done at triage

• Taking of vital signs

ASSESSING SEVERITY OF ILLNESS• Airway

• Breathing

• Circulation

• Disability (Neurological)

• ExposureLIFE-THREATENING ILLNESSES ACT BY EXERTING THEIR EFFECT ON THE ABOVE

AIRWAY

• Stridor

• Tracheal tug

• Drooling

BREATHING

• Increased work

• Increasing fatigue

• Decreased effectiveness

BREATHING

• Increased work• Recession RR• Grunting• Nasal flare• Accessory muscle

BREATHING

• Increasing fatigue RR breath sounds chest/abdominal movement• Apnoeic spells (c.f. periodic breathing)

BREATHING

• Decreasing effectiveness• Cyanosis Alertness

CIRCULATION

• Pallor/Peripheral cyanosis capillary refill

DISABILITY

• Conscious state

• Eye contact

• Activity

• Cry

DISABILITY

• Conscious state• Lethargic/Dull/Expressionless• Irritable• Not recognizing mother• Seizures• Not responding to pain• Quiet/Unresponsive

DISABILITY

• Eye contact/Smile• Lack of social smile• Not Fixing/Following/Focusing• Glassy stare

DISABILITY

• Activity• Require assistance• Not ambulating

DISABILITY

• Cry• Unable to be placated by mother• Whimpering/Sobbing• Irritable• Weak/Moaning/High pitched

EXPOSURE

• Mottled

• Petechiae

• Unexplained bruising (NAI)

VITAL SIGNS

• Different reference range for different ages

• BP is an important value often forgotten

• Hypothermia is suggestive of sepsis

• Pulse oximetry - ‘the fifth vital sign’

• Weigh the child

• Check blood sugar

WHY WEIGH THE CHILD?

• Changes of weight are a good guide to degree of dehydration

• Determines drug dosing

• Determines IV fluid calculations

SIGNS OF SEVERE ILLNESS

• Resting stridor

• Marked intercostal/sternal recession with accessory muscle use and tachypnea

• Cyanosis

• Capillary refill > 4sec (normal < 2 sec) / HR

• Impalpable pulse or hypotension or HR

• Not fixing/following or responding to environment

REASURRING SIGNS

• No stridor or only stridor with activity

• Mild recession

• Good colour

• Capillary refill < 2 sec

• Responding to mother and examiner/Able to be placated by mother

PRACTICAL TIPS

• Maintain a calm and reassuring manner (helps the parents and yourself)

• Keep a handy reference at triage of age-related ranges of paediatric vital signs

• When assessing capillary refill - choose an area of the trunk and apply pressure for 4 secs before releasing

PRACTICAL TIPS

• Assess pulse at brachial artery (inside elbow)

• Use age appropriate BP cuff (width 2/3 circumferance)

• Use paediatric probe for pulse oximetry

PRACTICAL TIPS

• Weighing the child• use proper paediatric scales (NOT adult scales)• ideally unclothed with small babies• Record to within 0.1kg for a neonate• Record to 0.5kg for an infant