This formula is not suitable, however, for use in a child aged <1 year; although a term newborn infant averages 3.5 kg, by 6 months the birthweight has usually doubled and at 1 year trebled.

Whichever method has been used to establish body weight, it is essential that health-care professionals are familiar and competent in its use (Resuscitation Council UK 2010).

Anatomical

A child’s airway goes through many changes; in the younger child the head is large and the neck short, which causes neck flexion and airway narrowing. The face and mandible are small and the tongue is relatively large and can obstruct the airway easily. Also the floor of the mouth is easily compressible and can be obstructed by positioning of the fingers during airway manoeuvres

The anatomy of the airway itself changes with age. Infants aged <6 months are nose breathers and, as upper respiratory tract infections are common in this age group, their airways are commonly obstructed by mucous secretions.

In all young children the epiglottis is horse-shoe shaped and the larynx high and anterior, making tracheal intubation much more difficult.

Physiological

There are many differences in the respiratory and cardiovascular systems of infants and adults. The infant has a greater metabolic rate and oxygen consumption, which is the reason for their increased respiratory rates, Stroke volume is also relatively small in infancy and increases with heart size. However, the cardiac output is the product of stroke volume and heart rate, so high cardiac outputs in infants and young children are achieved by rapid heart rates. Tables 17.1–17.3 give some of the respiratory indices.

Table 17.1 Normal respiratory rate according to age

Table 17.2 Normal heart rate according to age

Table 17.3 Normal blood pressure according to age

Immune Function

At birth the immune system is immature so babies are much more susceptible to illness.

Psychological

Children vary greatly in their intellectual ability and emotional response. Knowledge of the child’s developmental structure is of great benefit. Infants and young children find it very difficult to communicate and the importance of non-verbal communication and fear must be thought about.

ABCDE APPROACH

The ABCDE approach (see Box 17.1), as for in adults (see Chapter 2), can be used when assessing and treating a critically ill child; the underlying principles of assessment, initial management and ongoing reassessments are the same. The general principles are as follows (Resuscitation Council UK 2007):

• Observe the child generally to determine the overall level of illness (i.e. Does the child look seriously unwell? Is he or she interacting with parents).
  
• Speak to the child and assess the appropriateness of their response; ask the parents about the child’s ‘usual’ behaviour.
  
• If the child is unconscious and unresponsive to your voice, administer tactile stimulation (gently shake the arm or leg). If the child responds by speaking or crying, this indicates that he or she has a patent airway, is breathing and has brain perfusion. Regardless of the child’s response to initial stimulation, move on rapidly to full assessment of ABCDE.
  
• Appropriate high-flow oxygen delivery should be started immediately.
  
• Vital sign monitoring should be requested early.
  
• Circulatory access should be achieved as soon as possible. Bloods for laboratory investigations and a bedside glucose should be obtained.
  
• Ensure personal safety.

Initial Approach to the Child

• Ensure that it is safe to approach the child; check the environment and remove any hazards.
  
• On approach to the child and before touching him or her, rapidly look around for any clues to what may have caused the emergency because this may influence the way the child is managed (e.g. any suspicion of any head or neck injury).
  
• Determine the responsiveness of the child; an appropriate way of doing this is calling the child’s name and telling him or her to ‘wake up’. For an infant it is appropriate to ‘flick the feet’ or pick him or her up if no trauma is suspected. A normal response implies that the child has a patent airway, is breathing and has cerebral perfusion. An inappropriate response or no response indicates that the child may be critically ill and help needs to be summoned immediately.

Assessment of Airway

If the child is talking or crying he or she will have a patent airway. In a conscious child it is important to establish airway patency: Is the airway at risk or obstructed? Airway obstruction can be partial or complete; the airway may be restricted by mucus or vomit and simple actions such as repositioning or suction may be required. A foreign body could be present; in unconscious children the tongue may fall backwards and occlude the airway. Airway obstruction may be demonstrated by difficulty in breathing and/or increased respiratory rate; if the obstruction is partial there may be ‘gurgling’ or ‘stridor’. It is important to note that, when assessing airway patency, chest movement does not guarantee that the airway is clear.

Causes of airway obstruction include (Resuscitation Council UK 2007):

• foreign body
  
• tongue
  
• secretions – vomit/blood
  
• respiratory tract infections
  
• altered level of consciousness
  
• pharyngeal swelling
  
• epiglottitis
  
• laryngo-/bronchospasm
  
• trauma – face/throat
  
• congenital abnormality

The repositioning of an airway is simply overcome using the head-tilt and chin-lift manoeuvre: place one hand on the child’s forehead and gently tilt the head back; in the infant (<1 year of age) this is the neutral position. For the child this is the ‘sniffing’ position with some extension of the head and neck required. If this position is not possible or any trauma is suspected, a jaw thrust manoeuvre can be performed, which is achieved by placing two or three fingers under the angle of the mandible bilaterally and lifting the jaw upwards.

In children with airway obstruction it is important to deliver supplemental oxygen as soon as possible to minimise the effects of hypoxia. If there is a reduced level of consciousness, airway compromise must be assumed; the familiar look, listen and feel approach can easily detect if an airway is obstructed.

Look

Look for chest and abdominal movements. If the airway is obstructed paradoxical chest movements (see-saw respirations) and the use of accessory muscles can be seen.

Listen

Listen for breathing: normal respirations are quiet, partial obstructed breathing is usually noisy whereas complete obstruction will be silent.

Feel

Feel for signs of airway obstruction: place your face in front of the child’s mouth to determine whether there is movement of air.

Treatment of Airway Obstruction

Once airway obstruction has been identified, treat appropriately. Simple methods such as suction, airway positioning, or insertion of oropharyngeal or nasopharyngeal airways are often very effective. As described earlier administer high-flow oxygen as soon as possible.

Assessment of Breathing

Once the airway is open it is important to assess for effective, spontaneous breathing. Appropriate management of airway and breathing is the priority in all seriously ill children. This is also achieved by the look, listen and feel approach.

Look

Look for general signs of respiratory distress; look at the respiratory rate, the work of breathing, tidal volume. Is there tachypnoea, central cyanosis, chest expansion, use of accessory muscles?

In children recognition of respiratory failure is based on full assessment of respiratory effort and efficacy, and the inadequacy on major organs (Resuscitation Council UK 2007).

Tachypnoea is usually the first sign of respiratory insufficiency (Smith 2003). As discussed earlier, normal respiratory ranges vary with age and it is important to consider this (see Table 17.1). Remember also that fever, pain and anxiety will alter the respiratory rate so it is more important to monitor the trend in the rate rather than rely on an absolute value (Resuscitation Council UK 2007).

Recession in the sick child is common and shows the effort of breathing; this may be sternal, subcostal or intercostal. The degree of recession gives an indication of the severity of respiratory distress. Infants and younger children can exhibit significant recession with relatively mild-to-moderate respiratory compromise, due to their highly compliant chest wall. However, in children over about 5 years of age recession is a sign of significant respiratory compromise (Resuscitation Council UK 2007).

The use of accessory muscles is also a common sign when the work of breathing is increased. The sternocleidomastoid muscle in the neck is often used as an accessory respiratory muscle (Resuscitation Council UK 2007). In infants this can cause the head to bob up and down with each breath – known as ‘head bobbing’.

Another common breathing pattern seen in severe respiratory distress is ‘see-saw’ breathing; this is the paradoxical movement of the abdomen during inspiration. It is a very inefficient respiration because the tidal volume is greatly reduced. Nostril flaring can also be seen in infants and young children.

Assess the depth of breathing. Ascertain whether chest movement is equal on both sides. Unilateral chest movement may be a sign of pneumothorax, pneumonia or pleural effusion (Smith 2003).

Children in respiratory compromise will usually adopt a position that helps their respiratory capacity. This position must be supported to maximise comfort and prevent further upset which may result in further deterioration.

The degree of increased work of breathing generally provides clinical evidence of the severity of respiratory insufficiency; however, there are exceptions to this (Resuscitation Council UK 2007):

• Exhaustion: children who have had severe respiratory compromise for some time may have progressed to decompensation and no longer show signs of increased work of breathing; exhaustion is a pre-terminal event.
  
• Neuromuscular diseases, e.g. muscular dystrophy.
  
• Central respiratory depression: reduced respiratory drive results in respiratory inadequacy, e.g. encephalopathy and medications such as morphine.

Pulse oximetry should be used on any child showing signs of respiratory distress and at risk of respiratory failure. An arterial oxygen saturation (SaO₂) of <90 % in air or <95% in supplemental oxygen indicates respiratory failure. It should be noted that SaO₂ measurements are unreliable when a child has poor peripheral circulation. When SaO₂ is <70%, pulse oximetry is inaccurate (Resuscitation Council UK 2007).

Listen

Listen to the child’s breath sounds a short distance from the face. Normal breathing is quiet. Noisy breathing indicates the presence of airway obstruction (Resuscitation Council UK 2007):

• Stridor: associated with partial upper airway obstruction, wheezing is generally an expiratory noise
  
• Wheeze: may be heard audibly or on chest auscultation with a stethoscope; it indicates narrowing of the lower airways, e.g. bronchospasm.
  
• Grunting: mainly heard in young babies, but can occur in small children. It is the result of exhaling against a partially closed glottis, and is an attempt to generate a positive end-expiratory pressure, thus preventing airway collapse at the end of expiration. Grunting is usually associated with ‘stiff’ lungs and is an indication of severe respiratory compromise.

If possible, auscultate the chest. Air entry should be heard in all areas of the lungs. The depth and equality of breath sounds on both sides of the chest should be evaluated. Any additional sounds, e.g. crackles or wheeze, should be noted and it is often useful to compare one side of the chest with the other. A silent chest indicates a dangerously reduced tidal volume and is an ominous sign.

Feel

If possible palpate and percuss the chest wall. Palpation may identify deformities, surgical emphysema or crepitus (suggesting pneumothorax until proven otherwise) (Smith 2003).

Percussion of the chest wall can demonstrate areas of collapse (dullness) or hyper-resonance (e.g. in pneumothorax).

Respiratory compromise also affects other systems of the body, including heart rate, skin perfusion and conscious level.

Management of Respiratory Compromise

The treatment of breathing problems depends on achieving a patent airway and effective delivery of oxygen. This will vary depending on the child’s clinical condition and age. Children who do have adequate spontaneous breathing should have high-flow oxygen delivered in a manner that is non-threatening and best tolerated by them, e.g. from a non-re-breathing facemask or nasal cannulas.

When breathing is not adequate (or absent) high-flow oxygen should be delivered by ventilation with a bag–valve–mask system. In situations where the child is exhausted and likely to require ongoing respiratory support (or is in imminent cardiorespiratory arrest), tracheal intubation may be indicated (Resuscitation Council UK 2007).

Assessment of Circulation

Appropriate management of the airway and breathing is the priority in all sick children, and should be assessed before moving on to circulatory status.

Circulatory failure is the clinical state where the flow of blood (and associated delivery of nutrients, e.g. oxygen and glucose) to the body tissues is inadequate for metabolic demand (Resuscitation Council UK 2007).

In children most cases of circulatory failure are a result of hypovolaemia, sepsis or anaphylaxis. Other uncommon causes include obstruction of blood flow, e.g. tension pneumothorax, or anaemia or carbon monoxide poisoning in which the oxygen-carrying capacity of the blood is reduced.

Initially children are compromised for reduced tissue perfusion so it is essential to promptly recognise and treat any child with compensated circulatory failure to prevent deterioration to a decompensated state. The familiar look, listen and feel approach can be used for the assessment of the circulation.

Look

Look at the skin temperature and colour, heart rate, capillary refill time (CRT) and conscious level.

The skin of a healthy child is pink and warms to touch. Signs of cardiovascular compromise include cool, pale, mottled peripheries.

Measure CRT; a normal capillary refill is <2 seconds but when there is reduced skin perfusion this is prolonged. In children with pyrexias or cool peripheries a central CRT (e.g. chest or forehead) is much more reliable.

Demarcation lines are also seen in very sick children – this is peripheral vasoconstriction and decreased perfusion which leaves a line between warm and cold skin.

Look for other signs of a poor cardiac output, e.g. reduced conscious level, or poor urine output, Parents of young children will be very aware of how many wet nappies their child has had that day. Normal urine output is 0.5 ml/kg per h (Smith 2003).

Listen

Measure the child’s blood pressure. In most forms of shock a child’s blood pressure (BP) is maintained within the normal ranges (see Table 17.3) for a long time; only when compensation is no longer possible will hypotension occur. In hypovolaemia, hypotension occurs only after approximately 40% of the child’s circulatory volume has been lost, so it is essential that compensated circulatory failure be detected and managed early before decompensation occurs.

Another important point is that the appropriate cuff size be used. The cuff width should be >80% of the child’s upper arm length (Resuscitation Council UK 2007).

Hypotension is a sign of physiological decompensation and indicates imminent cardiorespiratory arrest.

Feel

Feel the central pulse; the heart rate initially rises to maintain cardiac output. Heart rates vary with age (see Table 17.2), but are also altered by fever, pain and anxiety, so other signs of circulatory function must be observed.

When the heart rate is unable to maintain tissue perfusion, the tissue hypoxia and acidosis result in bradycardia. The presence of bradycardia is a pre-terminal sign.

The pulse volume gives a subjective indication of stroke volume. Is the pulse strong or weak, thready or bounding or is there a difference when comparing central and peripheral pulses? Is a pulse present at all?

Circulatory compromise also affects other systems of the body including respiratory function and conscious level.

Management of Circulatory Compromise

The treatment of circulatory problems depends on achieving a patent airway and effectively managing ventilation with delivery of high-flow oxygen before turning attention to circulatory procedures (Resuscitation Council UK 2007).

Immediate life-threatening causes of circulatory failure must be sought and urgently treated.

Insertion of, ideally, two large-bore vascular cannula should be performed rapidly; if after three attempts or 90 seconds this is unsuccessful, then the intraosseous (IO) route should be used. Placement of an IO cannula involves insertion of a needle through the skin, periosteum and cortex of the bone, into the medullary cavity (Resuscitation Council UK 2007). The preferred sights are the anteromedial surface or the lower end of the tibia so as to avoid the growth plates. This route, once inserted, can be used to deliver all resuscitation fluids, medications and blood-derived products.

Unless contraindicated (e.g. cardiac failure) volume replacement should be initiated as soon as possible. A 20 ml/kg bolus of crystalloid solution, usually 0.9% saline, should be given as soon and as quickly as possible. The child’s circulatory status should then be reassessed and, if signs of failure are still present, this should be repeated. A further infusion, making three in total, is also available if required while the underlying cause is sought. If the cause of the circulatory failure is identified as haemorrhage, blood products must be considered. Glucose-containing solutions should never be used for volume replacement because they can be dangerous, causing hyponatraemia and hyperglycaemia (Resuscitation Council UK 2007).

Assessment of Disability

After appropriate management of the child’s circulatory airway, breathing and circulation, an evaluation of the neurological status should be made.

Causes of altered conscious levels include hypoxia, hypoglycaemia and medications (e.g. for status epilepticus) so it is very important to:

• review ABC to exclude anything previously missed
  
• check the medication already received for drug-induced causes
  
• undertake a bedside glucose measurement to exclude hypoglycaemia.

A rapid assessment of conscious level can be carried out by using the AVPU score.

Related posts:

Monitoring Nutritional Status Monitoring Hepatic Function Monitoring the Critically Ill, Pregnant Patient Monitoring a Patient Receiving a Blood Transfusion Record Keeping Monitoring During Transport

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