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Being presented with a critically unwell child is very stressful regardless of your level of experience and for a newbie to pediatrics, it fills doctors with fear and dread without a structured approach, there is a risk you will freeze under the pressure of the emergency which can really dent your confidence and there's a risk that you would mismanage the emergency. I'm Doctor Matthew Sayers, a consultant, pediatrician with over 10 years experience managing pediatric emergencies. And in this video, I am going to share my approach to assessing and managing critically unwell pediatric patient. Links to all guidelines and documents in this video are available in the video description for any unwell child. You should adopt a standardized ABCD E approach that I will talk through. Now, the ABCD E approach should be a rapid assessment which integrates examination, investigation and resuscitative management in a systematic way. Communication with parents is very important in addressing key aspects of the history and providing reassurance, but it should not delay your ABCD E assessment. Even if the parents are very distressed, if you have multiple staff to help aspects of the assessment and management can be delegated and performed simultaneously but it is important that there is a leader who ensures that all aspects of the assessment are addressed appropriately, assess the airway. If the child is conscious and talking or crying, the airway is patent. Listen for noises such as snoring or stridor, which can indicate an obstructed airway. If the airway is obstructed from unconsciousness, open it with a head tilt, chin lift or jaw thrust maneuver. If there is significant Stridor, avoid annoying the child and keep them in a comfortable position with their parents for any airway issue, seek senior help urgently if there is significant stridor, barking cough and signs of croup, dexamethasone should be given along with nebulized adrenaline. If there is severe respiratory distress. If stridor is associated with facial swelling, skin rash and shock, this may indicate anaphylaxis administer an EpiPen intramuscularly immediately. If there is a history of foreign bodily ingestion with Stridor, call for urgent ent and anesthetics assistance. Once you've addressed any airway issues, now assess the child's breathing. Breathing has three aspects, the effort of breathing, the efficacy of breathing and the effects of breathing. The respiratory rate is the simplest way of assessing the effort of breathing. Remember, however, that respiratory rate can be elevated for other reasons such as infection temperature and acidosis. And that a slow respiratory rate or brief apneas can be a sign of significantly deteriorating efficacy and effects of breathing. Also assess the effort of breathing by looking at tracheal tug, intercostal and subcostal recession and by the child's ability to speak in full sentences, the efficacy of breathing is assessed by listening to both lung fields and assessing how well air is moving in and out of the lungs. Loud, clear entry to both lung bases indicates good breathing efficacy. Bilateral wheeze indicates restriction of air moving out of the lungs. Reduced air entry indicates poor efficacy of breathing in this area. So in lifethreatening, asthma attacks, there may be reduced air entry bilaterally without significant wheeze crepitations or bronchial breathing in a focal area indicates probable infection causing poor breathing efficacy in this area. A unilateral area of absent breath signs with associated hyperresonance can also indicate a pneumothorax. The effects of breathing can be assessed using oxygen saturations with oxygen saturations less than 94% particularly less than 92%. Indicating severe respiratory difficulty, agitation and confusion can also be clinical signs of poor effects of breathing. A venous blood gas can be performed to assess the effects of breathing by measuring Ph and CO2 arterial blood gasses are very rarely performed in pediatric patients outside of the intensive care. A chest X ray can be useful to assess the cause of respiratory difficulties in Children. However, it does not assess the effort efficacy and effects of breathing breathing problems should always be treated with additional oxygen initially via a non rebreather mask if tolerated if the child has significant wheeze and is over one such as in asthma or in viral and just wheezed nebulized salbutamol and ipratropium combination neb should be given generally as three sets of back to back nebulizers along with steroids, either prednisoLONE or dexamethasone in Children under one with wheeze snuffly nose and reduced feeding. Bronchiolitis is the most likely diagnosis. This is managed supportively with extra oxygen, restricting fluid intake, feeding, support with nasogastric feeds or IV fluids and high flow oxygen therapy. In severe cases, there is no benefit to nebulizers in these Children. Once you have addressed breathing problems, you can now move on to the circulation assessment, assess the child's heart rate. An elevated heart rate can be caused by a circulation problem. But this is a very nonspecific sign as it is often elevated in pain, anxiety temperature and with nebulized salbutamol, always remember to attach ECG monitor leads to the child to help identify an arrhythmia causing an elevated heart rate, particularly if the heart rate is over 200 BP is often normal or high even in Children with significant hypovolemia. However, if it is low, this must be addressed urgently as this is a late sign of severe shock capillary refill time should be checked centrally on the child's forehead or sternum. Press firmly with your finger for five full seconds. Counting aloud can be helpful to ensure you press long enough and then count the number of seconds it takes for the pale area of skin below your finger to return to its previous color. A cap full time of greater than two seconds indicates signs of shock. Also look at the skin color looking for pallor and mottling. This is a marbling color that poorly perfused skin gets in shock. Although do check with parents if this is new for the child. As some Children have a mottled complexion naturally feel the hands and feet to see if they are cold and assess for hydration status. By looking to see if the lips and mouth are dry. Ask the parents about urine output in the preceding 24 hours and significantly reduce urine output indicates dehydration and poor perfusion. A venous blood gas can be helpful to assess circulation with low ph low bicarbon base excess and elevated lactate being commonly associated with per perfusion. If there is significant hypovolemia and shock, call for senior help urgently get IV access, send blood cultures relevant blood investigations and a venous blood gas and give it 10 mils per kilo fluid bolus of normal saline or Herman's and reassess ABCD. E after this further fluid boluses may be required if IV access cannot be obtained. Quickly, call for senior help and consider inserting an intraosseous needle if you're competent to do so. If the cause of shock is not apparent or may be due to sepsis, give broad spectrum antibiotics urgently after blood cultures have been obtained. If there is an arrhythmia, seek senior help urgently and follow the relevant APL S treatment protocol. If there is a significantly elevated blood sugar on the venous blood gas with an associated low ph check blood ketones and treat using the DK A algorithm. Once you have addressed circulatory problems, you can move on to disability assessment. That is neurological assessment, assess the child's level of responsiveness. Are they alert? Do they respond to voice only? Do they respond to pain, lonely or are they unresponsive? Any child that is responding to pee and only or unresponsive are likely to have an insecure airway. And anesthetist should be contacted urgently to assist, check a Glasgow coma scale in any child that is not alert, remembering to check the best response rather than the initial response, assess the child's pupils which should be equal and reactive to light, small dilated or unreactive pupils indicate severe intracranial abnormality or neuro inox and senior help should be sought urgently. Are there any signs of seizure activity such as repeated myoclonic jerks, spasms, clonic movements of the arms and legs or tonic, eye deviation in babies with the patent fontanelle examined for any bulging which can indicate increased intracranial pressure. Don't ever forget glucose in any child who is seriously unwell as they have very little metabolic reserves and hypoglycemia is common in any disease pathology. If there is very severe hypoglycemia, unexplained by significant vomiting and poor oral intake, send a hypo pack before treating the hypoglycemia as inborn errors of metabolism or endocrine problems can present in this way, hypoglycemia should be treated promptly with two mils per kilogram of 10% dex dose given intravenously and the blood sugar rechecked. A few minutes later, once you have addressed d problems, you can move on to e expose and examine. This is a systemic examination to find other causes of severe illness. Check the child's temperature if not already done. So as an elevated temperature is suggestive of infection, either bacterial or viral. Examine the skin for rashes, particularly rashes that do not fade under pressure. Indicating petechia or purpura, which can be associated with meningococcal septicemia also examined carefully for bruises, particularly in premobile babies, which can be suggestive of non accidental injury. Examine the amdipin and genitalia, looking for surgical pathology such as severe tenderness guarding, rebound, strangulated hernias or signs of testicular torsion. Once you have completed this assessment and started treating abnormal physiology, return to the start of the assessment and review if the child is improving or deteriorating. If the child deteriorates at any stage during the assessment, return to the start and reassess using the CM ABCD E approach at all stages. Remember to consider, do you need senior help? The Peds Emergency App is a very useful resource that I would recommend you download from the Android or Apple app stores. This gives you key information on treatment algorithms calculates emergency drug doses based on weight and tells you how to make up and give these drugs. There is a free module endorsed by R CPC H on Spotting the sick child, which provides more detail and examples on the assessments above and is very useful for new doctors and pediatrics, advanced pediatric life support and European pediatric, advanced life support are very useful face to face courses which teach advanced resuscitation assessment and treatment of pediatric emergencies. And these are mandatory for all pediatric trainees within the UK. Thanks for watching. We hope you find this video useful. Please like comment and subscribe to our channel on youtube, Instagram and Twitter. We release regular videos across our platforms and we hope to see you again soon.