Approach to the paediatric patient

1.1 Approach to the paediatric patient



Ian Everitt, Andrew Jan, Andrew Harris, Tom Everitt, Lisa Coutts




Essentials



1 Gaining rapport with the child and the confidence of the parents is the key to assessing children.

2 A child needs to be approached according to chronological and developmental age.

3 Observation is a vital diagnostic tool, which is vastly more important in children than in adult patients.

4 The need for investigations is a balance between an invasive stress on a child and the potential gain of information to aid decision making.

5 Always back up discharge with a concrete action plan and definitive follow up.

6 It is often more important to exclude serious illnesses than make a definitive diagnosis.

7 Addressing parental concerns is an important part of the therapeutic process.

8 Emergency physicians should stay within their comfort zone and when in doubt, consult.

9 A febrile child should be considered as potentially sick until one can confidently conclude that he/she is well following a thorough assessment.

10 Always reflect on the potential fears of the child and parents.


Introduction



Who sees paediatric emergencies?


It is essential that all doctors are familiar with the recognition and management of the seriously ill child. The majority of children presenting to emergency departments are either taken to tertiary paediatric centres or mixed departments that see both adults and children. A small number will arrive, due to close proximity in an emergency, at adult departments where staff may be less familiar with the management of children. Likewise, paediatric emergencies occur remote from emergency departments and may require stabilisation by general practitioners, paramedical staff or laypersons prior to subsequent referral. It is an important role of emergency departments to be an available resource to support the community in the management of paediatric emergencies. This function may occur through advisory, liaison and educative processes.


Some critically ill children will arrive in a more predictable fashion via ambulance and some preparation can occur to plan for their initial treatment. On the other hand, a child in extremis may well be rushed in from a family car, without any prior warning of their arrival. Systems of preparedness for these situations are critical for the immediate assessment and optimal early management of children by emergency department staff (see Chapter 2).



Evolution of paediatric emergency medicine


In Australia and New Zealand there are currently only nine stand-alone tertiary paediatric emergency departments. Hence, the majority of paediatric patients present initially to mixed departments where approximately 10–30% of attendances are paediatric. This is similar to the UK, Canada and USA. Some of these children will require subsequent referral to a paediatric tertiary centre for ongoing specialist care. The role and functioning of emergency departments has changed dramatically over the past three decades. Paediatric emergency medicine (PEM) has now developed as a speciality of paediatrics and emergency medicine. The initial assessment and stabilisation of paediatric patients, which in the past was often deferred to intensive care or anaesthetic colleagues, is now an important role of emergency physicians. In Australasia, the development of PEM as a subspecialty of the College of Paediatrics has seen the establishment of a supervised training scheme by the Paediatric Emergency Medicine Special Interest Group for advanced paediatric trainees. A joint training programme overseen by both the Australasian College for Emergency Medicine and the Royal Australian College of Physicians oversees the training qualifications of paediatric emergency physicians. It is paramount that physicians and trainees in both specialist and general emergency departments are well trained and the facilities are appropriate for the resuscitation of critically ill children. Hence, the education and training of emergency physicians in the management of common paediatric emergencies is an important role of both paediatric and emergency colleges. Whether a trainee is seeking a career in a paediatric or a mixed emergency department, experience gained in both environments with exposure to the teaching of both paediatricians and emergency physicians is advantageous. Likewise, a rotation in paediatric intensive care and paediatric anaesthesia provides additional skills in resuscitation, airway management, haemodynamic support and monitoring of critically ill children. The APLS (Advanced Paediatric Life Support) and ATLS (Advanced Trauma Life Support) or equivalent courses are invaluable additional resources and are requirements to satisfy fellowship qualifications in the training of physicians who will be managing paediatric emergencies.



Identifying the potentially sick child


Of the vast number of children attending emergency departments, approximately 2–5% are classified as immediate emergencies (Australasian Triage Scale (ATS) 1 and 2) that require urgent assessment and management.1 Importantly, children can present with a less urgent triage category, but may rapidly deteriorate from evolving sepsis or airway compromise. The majority of paediatric presentations consist of less emergent problems involving a wide spectrum of injuries and illness. Of this group of paediatric patients there is a subset where the diagnosis is not immediately apparent. Thus, paediatric patients can generally be divided into three broad groups: the obviously well, the obviously sick or the potentially sick child. One of the major tasks for the emergency physician is to identify the ‘sick child’ from a large undifferentiated group of children who may present as potentially sick. It is by a ‘filtering process’ via history, examination, observation, investigation and consultation that one identifies the potentially sick child (Fig. 1.1.1). This group of patients includes: those children who have progressed to a severe form of a usually benign illness; those with early, subtle signs of a serious disease; or those who on initial assessment appear unwell, but require investigation to help rule out serious disease. It is often through observation of a child, that one is able to more accurately assess each of these possibilities.2 With experience, the ability to appreciate a ‘sick child’ improves; however, a good rule, particularly in the younger child, is, if in doubt, investigate, admit for a longer period of observation or seek the second opinion of a colleague.


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Fig. 1.1.1 Algorithm of paediatric decision making.



Children with fever


The concept of ‘occult bacteraemia’ (OB) highlights the difficulties in detecting significant illness in febrile young children. With the recent advent of widespread vaccination to the common agents of occult bacteraemia (Hib, pneumococcus) the prevalence of paediatric sepsis has diminished significantly and the clinical experience of managing septic children has been diluted in developed countries. Hence, one needs to have a planned approach to the assessment of febrile children at various ages. Bacteraemia can in its most manifest form present as a febrile, pale, pasty, mottled child, centrally warm but with cool peripheries. Some young children with bacteraemia, however, can appear completely well apart from fever. Investigations may help identify them with a high white cell count or c-reactive protein (CRP), but these inflammatory markers are unfortunately often non-discriminatory between benign and serious causes. The problem is not so much that children with OB are sick at that moment of time, but the possibility of the later development of serious bacterial sequelae necessitates timely treatment. Conversely, many bacteraemic children will spontaneously clear the organism without therapy. Therefore, these children remain in the potentially sick category of patients and are obligated to have either admission for observation or discharge with frequent planned reviews for sequelae and a definitive action plan for their parents should the condition change. The evidence for the use of prophylactic antibiotics in these children is controversial. The age of a patient and height of the temperature are useful risk factors to consider in the approach to individual patients. In children less than one month, any fever is significant, whereas older children are more at risk of serious illness with higher temperatures. Likewise, hypothermia can occur in overwhelming sepsis, particularly in neonates and infants.



Evolving illness in children


Due to differences in anatomy, physiology, development and psychology, children’s diseases are age specific, with serious illness often taking time to evolve.3 Many children present to an emergency department in the early stage of an illness and making a definitive diagnosis may require time. The clinical status of paediatric patients may also change rapidly. This can occur in response to prior trauma, evolving sepsis, toxin absorption or a seizure, and necessitate a change in the initial priority to receive treatment. The younger the child, the greater the potential for rapid deterioration as the early manifestations of a serious illness may be subtle and non-specific. One must be vigilant for the early signs of compensated shock such as tachycardia, decreased capillary refill, mottled skin, cool peripheries, decreased urine output, or drowsiness. Early detection and fluid resuscitation at this point may prevent hypotension in a child with evolving sepsis. Children with severe and deteriorating respiratory illness will manifest fatigue. It is the early recognition of children with serious illness or the potential to deteriorate that is critical to the timely initiation of effective treatment.2 An important principle in emergency paediatrics is to be proactive. One must be aware of the importance of regularly reviewing a child’s response to a given therapy, escalate treatment if required and be vigilant for subtle signs of deterioration.



The environment


The physical environment of the emergency department needs to reflect a paediatric milieu with appropriately equipped cubicles for the reception of children accompanied by their carers. Despite the noise inherent in a busy department of sick children, the environment should be as calm and relaxed as possible. Wall or ceiling posters, mobiles, a selection of toys and books are useful to distract younger children from the distress and threat of an unfamiliar hospital environment. Posters of current popular characters such as ‘Teletubbies’, Blues Clues, Shrek, Wiggles or Harry Potter are useful. Not only do these characters make kids feel happy, but their active recognition provides a useful CNS diagnostic tool. A few initial moments gaining a child’s confidence with a toy will usually reward the doctor with a more rapid and thorough assessment of the reluctant child. Supplies of stickers or bravery certificates are excellent rewards to have on hand for young frightened children who have undergone imaging or blood tests. If possible, in a mixed department, children should be completely separated from adult patients. Adult patients who are behaviourally disturbed will be distressing for a child and family to see or hear in a nearby cubicle.


Likewise if a child is to undergo a procedure during which he may become distressed, such as intravenous insertion or laceration repair, it is best performed in a closed dedicated procedure room. This will avoid visual or auditory distress to other children and parents. A mounted television/video monitor in this setting can be an excellent distraction during procedures, as an adjunct to analgesia and sedation. For neonates and small infants a radiant heater over the examination bed will aid temperature stability, examination and often the discovery of veins for cannulation.


The paediatric resuscitation area should include wall charts, which refer to emergency algorithms and drug dose guidelines, which can be rapidly referred to during the resuscitation of critically ill children. A white board is handy for pre-sizing and dosing for the imminent arrival of a sick child. Updated clinical guidelines in hard copy and electronic form in the management of common paediatric emergency conditions are a useful resource to be available within the department. Clinical pathways initiated in the emergency department can be useful in ensuring consistency of management from all levels of medical and nursing staff, as well as improving continuity of care in children who require admission to an inpatient unit.



Triage


Paediatric patients arriving in the emergency department should undergo triage according to standardised Australasian Triage Scale (ATS 1–5) so that they are seen in a prioritised fashion according to acuity. In mixed emergency departments where triage nurses may have had less paediatric experience, there has been a tendency to up-triage paediatric patients.1 The use of scoring systems for specific conditions or a Triage Observation Tool may be helpful in improving the reliability of triage in young children, who may present with non-specific symptomatology.4 A secondary nursing assessment should occur when the child is admitted to a cubicle, with further observations performed at the bedside, so that any change in condition can be detected early and acted on promptly. The senior doctor in the department should immediately be informed of children triaged as ATS 1 or 2 to direct timely management. In times of high workload, children with an ATS 3 may not be definitively assessed within 30 minutes and should have a senior doctor rapidly assess status and initiate therapy, if required. It may be necessary to modify normal triage systems when emergency department numbers are affected by surges in demand when significant influenza outbreaks or the like occur.



Fast tracking


Some initiation of treatment is appropriate during the triage process, such as the provision of analgesia for pain or an antipyretic in a child symptomatic of fever. It is important that children with pain are given early and appropriate analgesia or have injuries splinted when required. This will facilitate a more comfortable, reliable and expeditious assessment. The use of opiates, when required, will only enhance, rather than detract from the subsequent physician’s physical examination.5 The use of visual analogue scales such as the Wong–Baker faces may assist the assessment of a child’s response to analgesia. A process of fast tracking appropriate children with single limb injuries for an X-ray prior to definitive medical review may improve efficiency through the department. Febrile children who present with a rash, not clearly due to a viral exanthema or benign phenomena, should be fast tracked to be seen by a senior doctor to consider the possibility of meningococcaemia. It is useful to have documented management plans for children who may recurrently present to the department. This includes conditions such as complex children, brittle asthma, cyclical vomiting or recalcitrant seizures where a clear plan of management can expedite care by ED staff.



The paediatric approach


The evaluation process of a child in the emergency department involves history, observation, examination and may include relevant investigations.


Each of these components needs to be considered in the formulation of a diagnosis and disposition plan. A child needs to be considered in the context of the family. The assessment of children in the emergency department setting can be both challenging and very rewarding. It is a challenge to modify the clinical approach according to the chronological and developmental level of the individual child. Likewise, treating paediatric patients is a rewarding area of emergency medicine, as children will often respond rapidly to management within the time frame of the emergency department attendance.



Gaining rapport


Endeavouring to gain initial rapport with a child and the confidence of the parents is the key to assessing children in the emergency department setting. An unrushed, gentle and caring manner will rapidly settle the fears and anxieties of most children and their parents. This usually allows the examination to proceed in a non-threatening fashion and improves the reliability of clinical signs. It will take time, experience and the observation of colleagues’ techniques for every emergency physician to develop their own individual approach to children. A thorough examination without causing distress to a child is very reassuring to a parent. Many children arrive at an emergency department miserable, in pain, fearful, or with some trepidation of what lies ahead. With a child-friendly approach by all staff, most will leave feeling much better and, hopefully, even having enjoyed the experience.



Age appropriate


The approach to any child in the emergency department is dictated by the child’s age and developmental level. It is useful to have a modified approach to suit newborns, infants, toddlers, preschoolers, school children and adolescents. An understanding of the concept of ‘the fourth trimester’ is useful in dealing with crying phenomena in the first months of life, which will often precipitate emergency department visits (see Chapter 1.2). A preverbal or developmentally delayed child won’t tell you of pain which has shifted to the right iliac fossa. An unwell 14-month-old clinging to mother may actively resist the initial attempts to be examined by a stranger. The absence of familiarity with a family or child that their family doctor may have may further impede the assessment of anxious children. When explaining procedures to children it is important to be age appropriate and above all honest. Never tell a child ‘you won’t feel a thing!’ prior to plunging a cannula through an EMLA anaesthetised cubital fossa. Rather, explain in age-appropriate terms what it may feel like and that it’s OK to cry.


Maintaining a child’s trust at all times is crucial and will positively influence any subsequent medical contacts the child may have. The demonstration of a procedure on a doll may decrease the anticipatory trepidation in a child.


The assessment of a child should always be carried out in the presence of the parent or carer, unless the child arrives by ambulance or other means without the parent/carer present, and the child’s medical needs warrant immediate attention. Otherwise, it is prudent in the non-urgent situation to provide a staff member to support the child and defer the assessment until carers are present.



Development appropriate


Infants particularly benefit from the constant presence of their parent in their visual field in order to avoid stranger distress and are often best examined in the parent’s arms. Neonates can be examined on the examination bed as long as they are kept warm. Toddlers, despite their evolving autonomy, will usually be less fretful if examined on a parent’s lap. It is a useful sign of illness or other cause to note when young children do not exhibit these normal stranger anxieties. The preschooler who enjoys a sense of play and imagination can usually be relaxed during an examination or procedure by storytelling or engaging in play with a toy. An anxious early school-aged child may respond to participation in the examination or being asked about school or other more favoured activities. Adolescents, on the other hand, need to be approached in a more adult fashion and should be offered confidentiality and the opportunity to choose whether their parents are present (see Chapter 30.1).


In the event of an unatonable child resisting any examination, one may have to modify the approach to gain essential clinical findings in a gentle but firm manner. It is unusual, however, for a child to remain ‘unexaminable’ if appropriate analgesia is given and the child is left for a period of time undisturbed.



Parental involvement


In order to provide emotional support, parents should be encouraged to remain close to their child during any procedures. Parents who appear at risk of vagal syncope are best seated away from the ‘viewing of action’ but still in their child’s earshot for verbal support. Children’s behaviour often mirrors that of their parents, so gaining the confidence of the parent will often make an anxious child relax prior to procedures. The use of a confident, calm, caring approach will be rewarded by a child who will allow a more reliable examination. It is very reassuring to the parents to see that the doctor is experienced in dealing with children and anticipates the expected anxieties and reluctance to examination that a child may have when unwell.



History


The initial contact with the family should include an introduction of who you are. The parents should be addressed and the child greeted by name, in an age-appropriate manner. It is important to consider one’s approach in terms of the needs of both the child’s illness and the parental concerns. The history is generally elicited from the parent or caregiver but it is appropriate, in a verbal child, to augment this information by directly questioning the child.



Critically ill child


Sometimes the normal routine of history, followed by examination will need to be altered in a child who arrives critically ill. The management will need to be expeditious and occur simultaneously with the gathering of pertinent information from the parents. Parents should be given the opportunity to remain at the bedside of their critically ill child undergoing resuscitation, with a dedicated support person.



Parental issues


The clarity of the history given by parents can be affected by parental distress, anxiety or sleep deprivation. One should begin the history in a focused manner according to the presenting complaint. Later it may be useful to explore individual parental anxieties. One of the most important questions to a parent is, ‘What is your biggest worry or fear?’ Some parents may have specific concerns such as a fear their febrile child has meningococcal disease when community alertness to this condition is heightened. Addressing this concern may occupy most of the doctor’s time. The parent of a child who has sustained an accidental scald or injury may be feeling distressed or guilty and sensitivity to this is required. Again, addressing guilt will involve much of the doctor’s time.



Children-specific issues


In younger children, certain symptoms are less specific. The report of vomiting in an infant may be due to meningitis, pneumonia, tonsillitis or urinary sepsis rather than gastroenteritis. The assessment of wellness or otherwise in infants can be more challenging due to their limited psychomotor activities. Indeed, their spectrum of normal behaviours involves sleeping, waking to cry or demand a feed, followed by a return to sleep. Hence, it is important to enquire into their feeding status and sleep/activity pattern as an indicator of compromise due to illness. One needs to carefully clarify what their current intake is compared to their normal breast- or bottle-feeding. An infant who is feeding less than 50% of normal has significant compromise. It is important to note the report of a young febrile child who remains lethargic and fails to smile or interact with parents. In the otherwise well-looking infant, who appears mottled, clarify with parents whether this may be usual for their child (i.e. physiological cutis marmoratum versus sepsis). In assessing young children with trauma, a thorough history of the timing and mechanism of injury, noting the child’s developmental capabilities, is paramount to detecting possible non-accidental injuries (see Chapter 18.2 on NAI).


Other useful information to cover in the paediatric patient history is shown in Tables 1.1.1 and 1.1.2.






Table 1.1.1 History warning bells

• Child taking less than 50% of normal fluids

• The child with prolonged lethargy

• No urine output for six hours

• Prolonged irritability or inconsolability

• Report of cyanosis, pallor, seizures or significant apnoea

• The child who has not smiled over a period of hours

• Nursing staff feel the child is ‘just not right’

• Unplanned re-presentations

• Parental concerns out of proportion to child’s illness

• Brought in by ambulance

• History not compatible with injury/?non-accidental injury

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Approach to the paediatric patient

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