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Brecca Gnant in off the seriously ill child put together by the South Hampton Children's Hospital Education Team. By the end of this presentation, we hope that you will understand how to identify seriously ill child, have more confidence in how to use a structured approach to rapidly Acessa seriously ill child, and also to have another standing of the initial interventions that you can make to stabilize a seriously ill child. Before we start, I'd like you to think about this question. How would you recognize seriously ill child? Pause the presentation for a few moments while you took down some of your ideas. So I'm sure you've written down some of these ideas that we've got here on this slide. Things like increased work of breathing, apneas reduced level of consciousness, one of the ones that sometimes I think it's easy to forget is the importance. With that, we should place on parental view and listen to what they have to say. When you're faced with a seriously ill child, you are going to use a structure to preach, to assess thumb on. The very first thing you're going to do is check for a response. If they are unresponsive. You will move immediately into your pediatric beer, less guidelines that I've signed pasty duty here if they are responsive. This is when you got to use the ABCDE structured approach that is a really a breathing circulation, disability and exposure. We're gonna look at those five elements in more detail now. The first priority is going to be assessment of the airway. When you approach your patient, you will hopefully hear sounds like talking and crying. And those sounds are really reassuring that the patient has a patent airway. You may hear some additional sounds, something like Strider or stutter or snoring. This could be due to an airway obstruction if the snoring ceases. When you wake the child on that, snoring is something they do normally, then it's not too much of a concern. But if those sounds continue in there awake or if they are making those sounds all the time, then you need to think about the cause of airway obstruction. We've got some of them listed here. We got things like congenital abnormality. They might have secretions or metal blood in the airway. They might have some sort of swelling due to infection or inflammation. We may know they have an infection. Such a scrip for hepatitis. They may have reduced muscle attain, and this might be something they normally have. But they are more, um, well, and the muscle tone is more pronounced. Because of that, they may have a foreign body in the airway on there, maybe trauma to the airway. Whilst we're assessing the airway, it's also a good idea, if able to, to look in the mouth for any potential obstruction. And this is when you might see secretions, vomit blood. You should also observe the chest for movement and look for signs of see so breathing. Sometimes it may appear that the child is breathing, but this If you see signs of this seesaw breathing, it may be an indication that although they are breathing, they are not creating any air flow into the lungs. Once you have assessed the airway, it may be that you need to make an intervention when you've looked in the mouth. If you conceive any vomit or secretions or even blood in the mouth, you construction what you can see. He's in your younger sucker. It's really important to keep the child calm, particularly if they're becoming anxious, as any problem with the airway could be exacerbated. If they become unsettled, it's important to position a child. They may have got themselves into a comfortable position that is optimizing their airway. All you may need to help thumb Teo either elevate the head or sit up if they're conscious, or if they have a reduced level of consciousness or are unconscious. This is when you're going to perform in a way maneuver. You will use the neutral position for the under ones, the sniffing position for the over ones on the head coach in there for the older Children and adults. If you're confident to do so, anything could. Your thrust might help. You can perform this a swell. You can also consider using an adjunct again if you think this is going to help on. If you know how to insert one correctly, make sure you're sizing it and using the correct technique for in session the attacks that you can use for or referring to. Airway Oh, a nasal friend. You away. If you were concerned at any point about the safety of your airway, it is important to call for help, really. And this is done by putting out a double to double, to emergency cool or by calling for help if there is someone around. Once you've made your assessment and performed any interventions that we talked about, it's important to go back and reassess. The question that you're asking yourself when you were reassessing is House has what I've done, made things better worse? Or are things the saying? If things are better on, do you feel now you have a patent airway. You can move on to assess breathing if the situation has stayed the same, but the airway was paid into all along again, you can move on to breathing. But if you've made things worse, you need to think about repositioning the airway or considering an alternative before moving onto breathing. Once you're confident that you have a patent airway or you've secured the airway by opening by using an airway maneuver, you can move on to your breathing assessment. Your breathing assessment is going to involve observing the risperidone, every rate, the work of breathing and the pattern of breathing, and all these things relate to the effort of breathing. But that child is making Children may well become more Tackett make. They may increase their work of breathing by having evidence off recession such as intercostal recession, sub coastal recession on sternal recession. They may have nasal flaring. They may have evidence of tricky tug they maybe head bumping and all these things will demonstrate to you that the child is trying to compensate to improve oxygenation. At this point, you also can look at their chest expansion. Are they moving their chest equally? When you are still take, can you hear crackles? Can you hear any wheeze is the reduced area and treat you to collapse? Is there any consolidation that you can hear? Hopefully, by this point, you have also thought about putting on some pulse oximetry and that you've observed the oxygen saturations in conjunction with the clinical assessment that you're making. Of course, pulse oximetry is only reliable if you have a good pulse on if you have good perfusion, so ensure that you've got a good trace. When you're reading that number, it may also be appropriate to do a blood gas so that you can look at gas exchange and use that information again in conjunction with everything that you can see clinically. Let's pause to think about these two definitions. Respectfully, distress is the clinical state with increased work of breathing. This is that compensated state that you can see during your assessment. Respectfully failure, on the other hand, is the loss of ability of the respiratory system to maintain adequate blood levels of carbon dioxide and oxygen. This is when they are no longer in a compensated state but are in fact moving into a decompensated state, and they're no longer able to maintain home your Stasis. Of course, you will know that it's possible to have respiratory failure without respiratory distress. And there were three reasons for that. Your child may be suffering from exhaustion. There's a chance that they have been compensating and they've been working very hard on. They've reached the point where they can no longer do that. Hopefully, you will have made an intervention before they reach the state of exhaustion. But it's always worth remembering that when they reach this point, it is a really worrying sign, and you should get help immediately. Some of our Children may suffer from your a muscular disease, and this is demonstrated by the fact that they have an inability to increase their work of breathing to compensate. So the in those Children, it is so important that you use the subtle signs such as their oxygen saturations considering doing a blood gas, considering if they're tiring and taking those signs really seriously. And then that's the group of patients with central respiratory depression. And this may come from a central reason, but it will say, may come from a over days off a p. It's, for example, in these cases again, the child can't increase their respiratory drive to compensate. If you've made your assessment and you feel you need to make an intervention, it may be that you need to deliver some oxygen. If your child is compensating well on, they are maintaining that's that's almost adequately. Then it may be appropriate to use some nasal cannula oxygen or some place mask oxygen just to improve those sets on toe. Help facilitate there compensated state. If you were more worried about their ability, tea oxygenate their blood and perfused that tissues, then this is the point where you're going. Teo, go for a non rebreathe oxygen mask. It 15 m and then we also have humidified high flow oxygen, and this comes as either a row will rock to flow most of the time. This is really useful for those patients that you think actually would benefit from high flow oxygen for a longer period of time. But just be aware that this does take a few minutes to set up and sometimes takes a few minutes to find. And so you may need to use something like a non rebreathe whilst you're setting up their humidified high flow. If your child needs some oxygen delivery, but also actually breathing is inadequate or have, in fact stopped, then you may need to provide ventilator support. You can do this by bag valve mosque if the child has stopped breathing. If you're trained to use and as Teepees, then it might be appropriate to deliver some Bentyl. A tree breaths buyer and has Teepees, and this is particularly useful if the patient is making some effort with breathing but just needs that little bit of extra help, particularly with some people, you could escalate their ventilation onto noninvasive ventilation, so maybe they've bean on humidified high flow, but they are continuing to work harder and not improving on this might be when you want to use, um, CPAP, ALS and bi Pap. And, of course, the final stage that we have is in intubation and ventilation, which you will do with anesthetic support either from the crash team or if you've called the anesthetic team directly. If you've made any intervention, or if anything has changed in breathing, that's when you're going to go right back to a and reassess. You're gonna check that your airways still patent and go back through your breathing assessment to ensure that you any intervention that you've made has made a difference. When you have stabilized airway and breathing, you can move on to assess circulation. Look at the child's heart rate. Is it normal for their age or rather, tachycardia? Core bradycardic? Have a look at the trend over the last few hours. If you have the information available to you, Children can put their heart rate up for a number of reasons, including pain pyrexia hypoxia. But it also could be a sign that they're starting to compensate, so it's important not to take that number in isolation but to complete your circulation assessment measure their competitively refill by pressing on the sternum for five seconds. The color should return within TI seconds. Failed their post volume. Is it normal, or has it become weak, or is it bounding? Taken early BP as this will form your baseline if you haven't already taken one. Children can sustain that, but pressure for quite some time when they seriously ill look at their skin color. Are they pale or mottled? What did they remain? Pink and well, perfused and we'll say, Feel the skin temperature all the cool on the edges. It's also we're finding out when they last past year in. At this point, shock is a clinical state in which blood flow and delivery of tissue nutrients does not meet. Metabolic demand should could be either compensated shock or decompensated shook in compensated shock. You may see the child is tachycardia with a prolonged capillary refill time, but that BP remains stable. It may be appropriate. Um, make some interventions in at this stage to prevent them going into decompensated shook, which is a very worrying and late sign. At this point, you may see a low BP and evidence off organ dysfunction. When you fully assess circulation, you may need to make some interventions at this point ensure that you have easy GI monitoring. If you haven't done so already on have the noninvasive BP cycling at either every few minutes or continuously of a break for it. Someone for the team may need to gain IV access and take bloods, and I guess at the same time you may be asked to prepare a fluid Bayliss if William Replacement is required and this will be 10 miles per kilo of crystalloid fluid. Finally, with the support of either the crash team or PICU involvement, you may be asked to prepare some minor trips if your other interventions haven't worked When you've made an intervention, or if anything has changed, you're going to reassess, starting with their way, making sure that's patent, making sure they are either still breathing or that they are being ventilated adequately on seeing if anything that you've done in circulation has made a difference. Before you move on, when you have stabilized, airway breathing on circulation or another member of the team is in the process of doing so, you can move on to assess for disability. You have already made a nurse s mint off their conscious level right at the beginning, however, is worth checking again at this point, and you're checking to see if they are alert, responsive to voice, only responsive to pain or unresponsive. On. On this slide, you can see the equivalent GCS. You can also do a formal GCS assessment. At this point, if you feel that it's appropriate or if they have abnormal neurology, you can look at any posturing. They may be quite floppy or hypotonic if they are seriously, um, well. But any abnormal posturing such a decorticate or decerebrate posturing is a serious cause for concern on must be escalated immediately. You may also see signs of fitting, and this may have been recognized earlier. One in your assessment. But sometimes subclinical fitting or very subtle fitting may be picked up. At this point. The child may be in pain, and it's worth assessing that at this point, check the child's peoples. Are they equal and reactive to light? And what size are they? Very large. People's that are unreactive or very tiny people's or unequal people's should be communicated to a senior team member. Don't ever forget to bleed coasts. Check their blood. Glucose is You may have already seen this on the gas, but if not, make sure you're doing a bedside test. The interventions you may make in disability will be to treat hypoglycemia, which normally we will do with two miles per kilo of 10% dextrose. If you've witnessed any seizure activity, then you're going to treat these using the salt algorithm, and you can refer to them to the algorithm on the salt website. You can administer any analgesia that is needed, but most importantly is to escalate your concerns. If you were worried about the neurology, then you must escalate that to a senior team member and again, once you've made any intervention, gave back to the beginning and reassess check. They still have a patent airway check. They're still breathing or being ventilated. Adequately check this circulation and that any signs off reduced cardiac output are being addressed and has anything that you've done in disability made a difference on finally exposure. Assess your child for any rashes, bruises or other injuries and ask yourself whether these fits with the clinical picture in front of you or the history that you've been given. It's also worth at this point to make sure that you've taken a temperature if you haven't already done so and also complete a sepsis screening tool when you've completed your exposure assessment, go right back to the beginning. Reassess. Starting with a ray in summary. Over the course of this presentation, we have looked at the A B, C D e airway breathing, circulation, disability exposure structured approach to a seriously ill child. We have acknowledged when it's important to reassess, and that is when changes occur and all when interventions are made. And hopefully we have given you more confidence when to escalate your concerns and how to do that. Thank you for listening.