Chapter 36. The sick child
Children tend to be treated with a greater sense of urgency than adults. This reflects both the instinct that most adults have to protect the young and the correctly held view that children can ‘go off’ quickly. While urgency is important, at no stage must a sense of panic prevail. The most important skill that comes with experience is recognising that a child is ill. Rapid and safe transport to hospital can be life-saving.
Recognition of serious illness
Health workers with a great deal of paediatric experience will intuitively recognise a very sick child. A systematic approach can be used following the familiar <C>ABC pattern, which is difficult to forget, even under pressure.
Assessment of the airway
• The airway may be patent or obstructed, protected or unprotected. Obstruction may be partial or complete and protection may be secure or insecure
• Any child who has anything other than an open and securely protected airway is seriously ill
• If the child is conscious, then a simple question such as ‘How are you?’ or ‘What’s wrong?’ should start the assessment and if you get a reply, then you have confirmed that the airway is patent, that they are breathing and that they have at least enough circulation to perfuse their brain
• In an unconscious child, an appropriate airway-opening manoeuvre should be performed and then breathing assessed.
The airway is at risk in any child who is not fully conscious
Assessment of breathing
The respiratory rate should be counted by exposing the chest. Exposure will also reveal recession. Recession is the appearance of indrawing of the chest wall that occurs while it is expanding during inspiration. It can be seen in a number of areas: intercostal (between the ribs), subcostal (below the ribs) and sternal.
| Age (years) | Respiratory rate (breaths/min) |
|---|---|
| <1 | 30–40 |
| 1–5 | 25–30 |
| 6–12 | 20–25 |
Wheezes (during both inspiration and expiration) indicate that respiratory work is raised because of the increased pressure associated with narrowing of the airways. Severe upper airway obstruction (such as that caused by a foreign body) can result in stridor. It is important to note that the loudness does not correspond to the severity of the problem. Silence in a previously noisy chest may indicate either exhaustion or total obstruction.
Hypoxia (reduction in oxygenation – <90% on air or <95% on oxygen) initially causes the heart rate to rise as the body attempts to deliver more blood to the tissues to make up for the lower concentration of oxygen. Eventually, however, the heart rate falls to below normal levels: this is a very serious sign and usually indicates imminent death. Hypoxia will also affect conscious level. First of all, the child becomes agitated but as the low oxygen delivery continues, drowsiness and then unconsciousness will ensue.
Bradycardia in a sick child or infant is a critical sign
Assessment of circulation
Palpate a large artery (carotid or femoral in a child or brachial in an infant) for 5 seconds to see whether any pulse is present
Decreased capillary refill time and increasing peripheral pallor and coolness are early signs of a failing circulation in children. The capillary refill is measured by applying gentle pressure (enough to squeeze out the blood) over the forehead or sternum for 5 seconds, then releasing the pressure and counting the time in seconds that it takes for the blood to return. The normal time is less than 2 seconds.
Pulse rate and blood pressure vary with age. In addition, the equipment needed (blood pressure cuffs) will be different depending on the size of the patient. This makes analysis of the blood pressure difficult.
Assessment of disability
Disability assessment involves a rapid evaluation of conscious level. Children with a reduced conscious level for whatever reason should be classed as seriously ill and treated accordingly. AVPU should be used initially, and whenever possible calling the child’s name is recommended. The painful stimulus should only be applied if there is no response to voice. An examination of the pupils for size and reactivity should be carried out at this stage.
Appropriate treatment
Performing procedures on children can be practically difficult and emotionally draining for the professional involved. Since the circumstances of most prehospital care are not ideal, resuscitative procedures should be limited to those necessary for safe transportation.
Airway
Opening and maintenance of the airway are both essential. Simple opening manoeuvres should be performed first – head tilt, chin lift and jaw thrust can be used in children. The head should be kept in the neutral position in infants (>1 year old), since overextension may cause deformation of the soft trachea with consequent airway obstruction.
Oropharyngeal airways can be used as simple adjuncts to airway opening. The appropriate size can be found by selecting the size that reaches from the angle of the jaw to the level of the incisor teeth.
The selected airway should be inserted the ‘right way up’ by depressing the tongue (using a tongue depressor or a laryngoscope blade) and slipping the airway into the mouth until the flange lies at the lips. Attempts to insert an airway using the adult twisting technique may cause considerable damage to the soft palate and may compromise the airway as bleeding occurs. Nasopharyngeal airways are not routinely used in children.
Do not interfere with a child who has severe stridor who is managing to maintain their own critically threatened airway. These children often wish to sit up during transport and should be allowed to do so. Forcing a child with stridor to lie flat may precipitate a respiratory arrest. Transport the child calmly to an advanced facility (preferably warning that facility of one’s imminent arrival so that appropriate preparations can be made).
Breathing
All children with inadequate breathing should be given oxygen in the highest possible concentration. Paediatric oxygen masks with rebreathing bags can achieve an inspired concentration of 85% with high gas flow rates. If respiratory support is required it can be given either by using a bag-valve-mask system or by intubating the child and using a self-inflating bag or ventilator.
An appropriately sized mask can be quickly selected by considering the size of the child’s face; the mask should cover both the mouth and nose. Three sizes of self-inflating bag are available – infant, child and adult. If there is any doubt, the larger bag should be used.
Attempts at intubation are only indicated in apnoeic children and then only once other avenues have been exhausted. Intubation may be unsuccessful and critical time should not be lost to failed attempts. However, if the decision to intubate has been made then the correct equipment must be selected and the correct technique used which will depend on the age of the child.
Intubation technique in children
Infants and very young children have a long, floppy epiglottis and this cannot be elevated sufficiently to allow the cords to be seen if the standard intubation technique is used. Consequently, it is necessary to directly lift the epiglottis with the laryngoscope. This is achieved by passing the laryngoscope almost to the oesophagus and slowly withdrawing it in the midline. As the laryngoscope is withdrawn, the epiglottis will remain elevated and the cords will come into view. A tube can then be passed through the cords and ventilation commenced. Adult blades can be used but straight paediatric blades will make this easier. Once intubated, ventilation should be started and the position of the tube checked by listening with a stethoscope and observing chest movements. Adequacy of ventilation is judged by looking for rise and fall of the chest.
Circulation
If circulation is present, then circulatory resuscitation is rarely necessary in the prehospital phase of care. Gaining intravenous access can be extremely difficult in children and time should not be wasted unless access is essential.
If immediate vascular access is required (usually because of progression or imminent progression to cardiorespiratory arrest) then a vein should be identified and the area prepared as usual; if standard techniques do not work within 90seconds then the procedure should be abandoned and an intraosseous line should be inserted. This is usually achieved in the medial surface of the upper tibia using a specially designed intraosseous needle. Both drugs and fluid can be introduced through this route.
For further information, see Ch. 36 in Emergency Care: A Textbook for Paramedics.
