The ill child – assessment and identification of primary survey positive children

Chapter 5 The ill child – assessment and identification of primary survey positive children





Introduction


Sick children present particular challenges to the pre-hospital practitioner. The anatomy of children is different to that of adults, and this can result in differences in the presentation and severity of a range of conditions. Paediatric physiology also differs from that of adults, and although this means children often compensate very well for significant clinical illness it also carries the risk that a severe problem will be overlooked or underestimated. When compensatory mechanisms fail in children, they often do so rapidly, catastrophically and irreversibly. The index of suspicion of the pre-hospital practitioner must therefore be higher than for an adult when assessing the ill child, and the threshold for hospital admission will consequently be lower than for an adult patient with similar findings. The emphasis should be on detecting and treating the seriously ill child at an early stage to prevent deterioration rather than to attempting to cope with a decompensated, critically ill child.


The paediatric section of this text is divided into two chapters. The objectives of this first chapter are outlined in Box 5.1.



Whilst this chapter concentrates on identifying or ruling out potentially time critical problems, it should be remembered that many children have problems that are not immediately life threatening. Common illnesses affecting children are covered in Chapter 6.



Significant anatomical and physiological differences between children and adults





Circulation


Infants and children have a relatively small stroke volume but a higher cardiac output than in adults, facilitated by higher heart rates (Table 5.1). Stroke volume increases with age as heart rate falls, but until the age of two the ability of the child to increase stroke volume is limited. Systemic vascular resistance is lower in infants and children, evidenced by lower systolic blood pressure (Table 5.1). The circulating volume to body weight ratio of children is higher than adults at 80–100 ml/kg (decreasing with age) but the total circulating volume is low. A comparatively small amount of fluid loss can therefore have significant clinical effects.




Range of normal development in children, and assessment strategies




Children


The developmental milestones for children aged 1–12 are outlined in Table 5.3.


Table 5.3 Range of normal behaviours in children aged 1 to 12 years















Age (years) Activity
1–2 Initially crawling and walking supported by furniture, then walking and running
Feed themselves
Plays with toys
Starting to communicate with increasing vocabulary; will understand more than they can vocalise
Independent and opinionated: cannot be reasoned with
Curious but with no sense of danger
Frightened of strangers
2–5 Illogical thinkers (by adult standards)
May misinterpret what is said to them
Fearful of being left alone, loss of control, and being unwell
Limited attention span
5–12 Talkative
Understand the relationship between cause and effect
Pleased to learn new skills
Older children may understand simple explanations about how their bodies work and their illness
Fearful about separation from parents, loss of control, pain and disability
May be unable to express their thoughts
Desire to ‘fit in’ with peers

The child can be observed from a distance initially whilst the history is being taken, and then approached slowly, preferably avoiding physical contact until the child is familiar with you. Children should remain with caregivers, and sit on their lap if they wish to do so. Young children respond to praise – admiring clothes or a favourite toy and recognising good behaviour are effective ways to win them over. They may be soothed by being allowed to play with their own toys or by being allowed to hold instruments such as a stethoscope. The caregiver can assist with the assessment, by removing clothes or holding an oxygen mask. Use of very simple words and toys can facilitate explanations to the child. Critical parts of the assessment can be undertaken whenever the child is at their most calm: consider examining from toes to head. A limited element of control can be given to the child, asking which part the child would like you to examine first. Do not lie to children and, in particular, never tell them something will not hurt if it will!


School-age children should be addressed directly. Using simple terms, an explanation of what you are going to do, what you think is wrong, and what is going to happen can be given, but the amount of information provided should be limited. Interventions should be explained immediately before undertaking them but negotiation about whether or not to perform necessary procedures is not usually rewarding in young children. Praise for co-operation is a good idea. Children are modest and this should be borne in mind by limiting the removal of clothing and the presence of non-caregivers.


Jun 14, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on The ill child – assessment and identification of primary survey positive children

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