CRF PAEDIATRICS DR ABDELGALIL (17.11.22 - Term 2, 2022)



This on-demand teaching session will provide medical professionals with the necessary information on identifying the sick child and performing a successful pediatric assessment. It will cover topics like the differences between adult and pediatric medicine, respiratory arrest and cardiac arrest, techniques and tools to assess breathing, and warning signs of illness in children. It will also discuss the A B C D E approach and different ages with respect to respiratory rate and other physiological and anatomical differences. This session is dedicated to understanding and carrying out a successful pediatric assessment.
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Learning objectives

Learning Objectives: 1. Recognize that Children require a different approach to assessment compared to adults and be aware of the physiological and anatomical differences. 2. Understand the signs that a child is in respiratory distress and know when to intervene in order to prevent complications. 3. Understand the importance of assessing a child's respiratory rate regularly and why it is important to look for trends in the data. 4. Appreciate the different Etiology with regards to respiratory distress in Children and the different factors that can contribute to it. 5. Be familiar with the A-B-C-D-E approach and understand how this can be used to assess a sick child.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

uh, good evening. Uh, I hope you can hear me. Well, my name is that after Jaleel, Um, a pediatric consultant. I'm practicing in the United Kingdom. Uh, for the last 20 years, Um, and I'm going to go through, um, the pediatric assessment for six Children. Um, this is a series of delivered identifying the sick child about two weeks ago, and I hope this will be useful. First of all, I I do believe that health and politics go together and without appreciating that injustice, anywhere is injustice everywhere and standing in solidarity with without borders with everybody who's facing injustice. Um, we cannot be even good doctors, Um, and therefore, uh, solidarity with, you know, uh, colleagues and medical students in Ukraine. Identifying the sick child. The principal at the moment is to try and prevent complications and identify that the child is sick as early as possible to treat. And this will be obviously will lead to a better outcome. Um, not identifying the child that is sick will lead to deterioration, will lead to complication, and the outcome can be very serious. Or even if the child survive, the child may survive with other secretly like neurological, see equally or other, uh, irreversible organ damage. So, um, Children are not small adults, and that's very important when you are doing your pediatric training or placement. So don't don't think that you can apply all of the principles that you've learned in adult medicine to pediatrics, and I'll be surprised if you tell me otherwise, because usually medical students will start with the adult medicine, and then they will come to the pediatric. So it's like at the end of their placement. By that time, you have gained experience. Uh, you know, looking after adult patient's. But you should not apply the whole principles or the same principles. Two Children. There are certain things which are similar, like taking history, you know, concerns about safeguarding. But you need to understand that the Children, physiology and anatomy is different. The etiology for why the Children get sick is different, and as well. You you can think about the child who's not immunized, how you know how many, uh, you know, uh, bacterial infection. They can develop in comparison to an adult who have developed immunity and, you know, had their vaccination had their immunization. Therefore, the physiology the anatomy and the etiology will be different. And therefore your approach should be different in Children. If we have a respiratory arrest without cardiac output, this is really not good news. And we need an immediate, um, you know, intervention. And if the child survive, there is a possibility that there will be a sequel. E um, some sort of, um, organ damage. Um, if we have respiratory arrest without cardiac output, especially if the child is in hospital or have been obtained by a trained, um, paramedic or health professional that the outcome will be better. Um, primary cardiac arrest in Children is not common. It's common in more in adults. But if it happens in Children, usually it is arrhythmia. And that would require, um, defibrillation. Um, you know most of the cases, but there can be as well, other intervention. Secondary cardiac arrest usually happens if there is a prolonged period of a hypoxia that we have not, um, managed. The child was not, you know, had did not have an access to, uh to treatment to treat the hypoxia on time. So prolonged hypoxia, very severe illness, sepsis and, uh, significant injuries or trauma. Whether nonaccidental or accidental in a serious for example, you know, multiple injuries in road traffic, accidents or injuries in conflict zone as we are seeing at the moment. So the honor to me and the physiology always remember is different, and we're going to go quickly through that, not in details. We are going to use the A B c D. E approach. And so I'm not talking all the time. I would like to see in the chart. And if if you would please, Hannah, let me know if you know how many of you are using the A B c d. E. Approach to assess, uh, sick Children and to assess Children in genera. Are you familiar with the A B C D E. Approach? If you would like to write in the chat, I would appreciate that I can't see the chart. So yes, someone said yes. Yes. Another. Yes. You can even show hands or do any Muji just to say that you know whether people are aware of the A B c D E. Approach. Yes. Thank you. Okay. So, um, if we progress by a which is, um Airway. Sorry. Sorry to interrupt, but people can use emojis like you just mentioned to make it easier. Then I think you can see it. You can use your emojis to react to questions if you'd like if it's some up or something like that. But please, as we're right in the chat and hopefully Hannah will be able to read that out for me because I can't see it. So if we look at the airway on here, I'm trying to make you aware that there are differences. So when you are approaching Children to resuscitate them, it is different from adults. So Children have. They have narrow airways. Um and, um, when we're using facemasks, we have to make sure we're using the right face mask for the size, Uh, of the child. I remember that we look at noon eights infants, preschool school Children and adolescents. If you use the wrong face mask, which is very small or very big, then you're not making a good seal, and you're not delivering oxygen appropriately. And if you're using a you know, a big mask and pressing on the eyes or pressing wrongly on, you know you can cause vagal stimuli. So first of all, because of the narrow airway and about not something we have to use the right face mask as well. Um, they have large tongue. Especially, uh, during, uh, you know, infancy and this large tongue can fall to the back and can block the airways. Um, because of the type of the etiology that, uh, of infection, they can develop a demand sweating of the airways very quickly. And, um, in the first year of their life, their nasal breather. So if you have blocked, you know, um, airway or your your mouth then and and blocked nose because of secretion, So they will be struggling and you can see that obvious with the work of breathing. Uh, the epic lotus is larger and floppier in Children, and therefore, if there is an inflammation or infection that can easily collapse, um, the infant have got a large OcciPet Still, the proportion of the head to the body is large, and therefore, when you come to open the airway, you have to put it in the neutral position not to extend it. Because in that way, um, you can block the airway and the larynx is positioned up upper. That in in in, uh, in adults. Therefore, if you think, oh, I can see that there is a foreign body in the mouse and you're trying to use your finger you can actually look. And therefore, you shouldn't take any foreign body unless you use specific or the special, uh, tools rather than your finger. So these are, you know, sort of, uh, basic differences in the etiology. Um, the monotony that you know of the difference between adults and Children when we come to the breathing. Uh, we, uh, the Children have got a relatively small lung volume. Um, and there is an increase in the number of the small airways from birth adult hood. Um, so you can imagine if a child has bronculitis or have you got a chest infection? They will be struggling, and and, uh, therefore, you need to provide support as soon as possible. They have low oxygen reserve, therefore, but they have increased rate of oxygen consumption. Um, and there, when you look at the mechanism of breathing, if you look at the rib cage still, um, in the infancy, there is cartilage. And so the the rib cage is is mobile, and you can see a lot of recessions, uh, intercostal precession, And then they use the diagram so you can see subcostal recessions. But if you have someone who's 10 years old and they're showing significant recessions, you have to be worried, because by that time, the rib cage is mainly bone, and they should not demonstrate cost intercostal precession. And so, of course, the recessions, unless they have significant respiratory illness and they are drifting towards respiratory failure. And so you can see the difference between the age group and the presentation of, uh, the same illness. Um, the respiratory rate you have to recognize in Children that we have different age groups. So this is one of the points that you have to notice. You can't apply the same principle like an adult, and you have to look, you don't you may not remember it. You don't have to memorize it. But you have to remember that during your natal period during infancy, during up to the age of four years, up to the age of nine years, it is different. And you can look, um, you know, in in any of the reliable apps, if you can't remember, it's important that, you know, one respiratory rate measurement is not always enough. You have to have a trend, okay? Because it can be, you know, deceptive. You may, you may think the child is well, but actually, the child is not well. You would think the child is not breathing fast. There is not a kidney to, but actually, the child is getting exhausted and actually is going towards respiratory failure. And therefore, you have to look at the trend either for improvement or for deterioration. So respiratory rate candy trees because of, you know, respiratory problem because of bronchiolitis because of ways. But it can increase with fever with anxiety, with agitation, which is can be common in Children. Uh, with you know, um, in age, it can be different between which one age and the other, and therefore an accurate record is important over time. So you can understand how is this child doing okay? What we're trying to say is, the observation over time is very, very valuable and very important. Uh, and, um, it can give you a clue about whether the child is improving or static or deteriorating. So if we go back in the chat and I ask you about what are the warning signs when you are assessing Be which is breathing. If you can write in the chart, What are the signs that you will be looking for If you are assessing, be breathing great, great, especially rate position while breathing whether they're drooped or going backwards. Well breathing extra moment sound of breathing, how they're breathing like rails or like, uh, strategy nous sturdiness Well breathing sound as oh, is it breathing? Breathing? Yeah, Someone has written something in the chart. I think, Yes, it's the same thing. Sounds breathing Good. Excellent. Good intervention. Anything else that people can think about Warning. Sign when you're assessing breathing in a child. Moment of test numb in spite the cost the recessions of Costa recessions One side is not moving. Okay, so let us look at the warning signs. So we have, first of all, decreased level of consciousness. These are the red because if you're getting exhausted or hypoxic, um, or there is a you know, increased levels of carbon dioxide. There can be decreased level of consciousness hypotonia as well. Um explained the exhaustion decreased respiratory effort in someone who's six and on a lot of oxygen can be a warning sign and we're talking about decreased below the normal standard. We're not meaning, uh, decreased respiratory effort Within the normal standard, cyanosis is very clear. Extreme pallor sweating because that indicates as well that the child is getting exhausted, hypoxic and hyper, uh, apnea and bradycardia is a very bad sign. Is usually pre arrest situation in Children. What we have we talked about is the work of breathing increased respiratory rate into acosta recessions. Sternal recessions, head bobbing in babies nasal flaring. So we don't want to reach the warning. The red signs. We need to identify that the child sick before that and treat them OK. Circulation the circulation. There are differences between adults and Children. Uh, and that's mainly because you know different physiology as well as etiology. So the oxygen delivery, um, which is depend on the arterial oxygen, the cardiac output and the oxygen demand will determine the oxygen delivery that's similar. But the hydration status will be different because the total circulating volume in in Children in infant and in young Children is very low, small in comparison to adult because of their size, And therefore, if you have a child who has, um, you know, be eating and drinking, having vomiting and diarrhea, they can present with significant, um, dehydration. Or if a child has a significant trauma, you know, leading to bleeding or if a child has a you know, volvulus or significant. You know, interstitial, um, surgical emergency. And they have a lot of, you know, third space fluid loss. Um, so they can easily their hydration. They can easily go into hypovolemia. And therefore, you have to, um, be very, uh, quick with your assessment with hydration in Children, because this is a very common presentation. The majority of Children, when they present, they have mild to moderate. Uh, dehydration is not like severe dehydration, but in some situation you can't face in your dehydration. Heart rate varies with age is similar to respiratory rate. You cannot always remember it, but you need to know that. And you need to have a reference when you are looking at the heart rate. Is that normal or not normal for this age? So don't take the the values for an adult 70 you know, bit. But that's fine. I'm I'm happy know and bradycardia is a very serious event in Children. It's really, really very serious event, um, and indicate that this child is going into another situation. When we talk about BP in Children, they maintain the BP because they have systemic vascular constriction of preferable constriction. Um, mechanism. That's really good. Uh, and therefore, if you have a normal BP and you're looking at the childhood stick, don't think that's reassuring because it's the last thing that will drop. And if you drop that, that's a problem. So, um, it is important to measure BP. Um uh, in all Children that present to accident, emergency or acute assessment tool, it always assess the child. And if you feel that the child is sick even if the BP is normal, you have to be careful. The same for Radic rd. A low BP is not a good sign in Children the red flag sign. And we prefer the mean arterial BP rather than system. You know, the systolic or the diastolic BP, um, again, BP changes with age. And remember that because you don't want to reflect on something, assuming it is normal. While it is not a look at the reference is one of the simple way of assessing circulation is the capillary refill time. And this is when you press. The best thing is centrally in the chest. You count for five seconds, you release your finger expecting the capillaries to refill within two seconds. Uh, less than two seconds. If that's prolonged, it indicates cardiac problem to get hypervolemia indicates sepsis. It indicates that this tribe is not well. So what are the warning signs that you will be looking for when you're assessing. See, we have mentioned some of them. So if you want to write or if you want to, um, you know, tell us directly, please. Again, Sinuses could also be the If the cardiac output is dropping, uh, is is very especially if it's in babies and immune eight congenital heart disease. Um, yeah, it's very serious. Um, yeah, I can see some people are commenting on the top. I can't read it. Someone has said, um, heart rate. Um, cyanosis. Uh, dropping of the consciousness again is a warning sign. So if we are earlier Sorry, Lethargic could also be there. Yeah. Yeah. So if you look at the, uh, recognition this time brought them earlier, and then the late recognition, the heart rate and we talk that it changes with age the pulse volume. So if you have a thready pulse, if you have, that's important because it indicate that you know, either there's a problem with the cardiac output or there is a low volume, um, as well, um, you can have the pulse character, not only the volume, the capillary full time. We have mentioned the BP we have mentioned deliver large liver indicates that the heart is failing and and, uh, and organ perfusion. So we talked about the level of consciousness, but from the history we can ask about the urine output if the child has been passing urine, as usual, if the child's not for a long time. Uh, then there is an indication about end organ perfusion, and you would be worried about multi organ. Um, you know, um, damage, um, and therefore you will be keen to, um, intervene as soon as possible. The late recognition, as we said, the alterations of the level of consciousness or the coma, the exhaustion or the tiredness, the cyanosis central cyanosis. But even if you have peripheral cyanosis, you have to think about what could be the problem. Seizure is a serious one. Systematic, Systemic Hypertension is a bad sign. Party character is a bad sign. Uh, and and this just, uh, to reflect that if you have a heart rate below 16 all ages, this is serious and CPR will be started. If you have heart rate less than 18 and infancy, that's serious. So this is why we're talking. Don't use, uh, adult physiology in pediatrics because you can say 70 you know, in in adults is fine. And in newborns, hardly blow 100 is serious when you will start, uh, later. Life support. So is disability. Basically think about new Europe in your assessment. Um, And when we talk about Children and adults, the behavior of Children when they are ill is different from adults. Um, they stopped playing. They are not eating. They become very anxious. They don't want to, you know, become sleepy. Especially if you have a nonverbal child. Whether because they are, uh, less than one or less than two or nonverbal Children because of, um, especial need, um, then you don't know what they can't express how they feel. Um uh with what? Where is the pain? What's going on? And you, Will you depend on your observation and you depend on their family or their care who know them very well. Who can tell you this is something wrong here? If they tell you that you have to take that seriously because you don't know the child And if they tell you that the child is not well, you have to take that seriously. Another factor that will affect your assessment if you you want to assess the neurological system is the pain assessment and the pain management. If Children are in pain, okay, they may be just crying. They may be upset, but they can't tell you. Um, not like a verbal child or a mature like you. You know, at the lesson I'm telling you that I have, you know, I have abdominal pain. It's hurting me. It's hurting me on the right side. So you think it was appendicitis? If you haven't been decided, For example, in a child who is less than five there, it's very difficult sometimes to elicit that so pain assessment and pain management is important, and there are guidance about using either faces or using um, scales or numbers so you can identify pain. Uh, as I mentioned the parents, and the care review is very important when you're assessing Children in general, but their neurology. So if you find the child was sleeping and you're just thinking, Oh, this child is sleepy But the mom said, Tell you that's normal. His time normal naptime. That's fine. If the mother tell you that's not normal, usually will be up jumping around. Um, and I'm really worried. He's so lethargic, is so sleepy it means something is wrong. So the usual assessment tool is the after alert, responding to very Palestinian lie, responding the pain and responsive but in intensive care unit. And when they are admitted, Children of the nurses will use the modified Glasgow coma scale. But I have to do is as useful when you have the first initial assessment. With that, you will have to feel the anterior fontanel for infants if they're bulging. If they are depressed, the pupils, equal and reactive to light the tone hypotonic hypertonic the posture flexure posture, normal posture, vocal side seems like they're not moving one side more than the other. And you have to check with the family because the child may have, for example, CP Sibur palsy. With him plegia unable to move one side. Is that the normal for him? Say no, That's not normal. That's not him. And indeed, we say, Don't forget blood glucose because if it's low, you need to treat it as an emergency. And low blood glucose can be associated with seizure can be associated with coma can be associated with lethargy. And it is common in Children and babies because they stop feeding when they are unwell and they don't take anything and therefore easily they can't develop. Happens licensing. I don't know whether there's any question, because before I moved to the following slide, nothing in the chart right now. So central Neurological assessment. You can have a primary neurological problem like meningitis. Thank you, Phil itis severe head injury or a child who has epilepsy will develop status epilepticus. That's a prolonged seizure that the child is not recovering from it, and this can cause a primary neurological problem when you're assessing that, but there can be a secondary neurological complication if you have prolonged hypoxia or untreated hypovolemia untreated hypoglycemia. If there has been drug, you know, over those whether intentional or accidental, a child found a tablets and they took it, or it has been taken for deliberate self harm Metabolic disorders. Um, if you look at the Rio cycle and, um, I know asset, you know, um and, you know, accumulation of waste products that may need to alter the neurological status and raised a C P for different reason can alter, uh, the consciousness level. And we have to identify that by looking at the pupils, the pulse and the BP and thinking about it, especially if the child is unwell because it can be treated. So we have moved to eat now, and Children were expecting for examination. So you can't say because the child is having a cough. I'm just going to listen to the chest. You need to have full examination of the child and full exposure with dignity and making sure, especially in young Children in infants and unit, that there is no heat loss, so you can't leave them uncovered or take their clothes for a long time. So you have to understand that as well. Measuring the body temperature is important whether it's fever and I, you know, in previous lectures, I'm sure and has been mentioned by other colleagues. We get very worried if there is a high temperature above 38 in Children or in infant below the age of six months or three months. But we get worried as well if the temperature is very low below the normal, expected because hypothermia can be a presentation of infection or senses. And hypothermia can be as well as part of serious trauma or injury. Or, you know, uh, drowning or a child has been in the cold weather for a long time in conflict areas looking for a rush and the skin mark is very important. And I would like you to write the chat box about what types of rashes would you be worried about? Or skin mods that will worry you while you're exposing the level of the e of the exposure. We would like to your back to think about the weight and the height of the child and the service area, because medication and Children, even fluids, will be given using the weight or the service area, and that can be actual weight. The child is well enough to check them the weight, or it can be an estimation because the child is annual and you can't ask them to stand or put them on the scale while you're looking at the child. It's important to think about safeguarding about deliberate self harm about injuries that the child may have, you know, been using cutting, for example, about congenital anomaly, the spine, the head, um, the sort of nappy area, the external genitalia. There's no ambiguous genitalia. The anus looks patent. Um, there's no this small fizzing. So in in babies, good look is very important because we talked about congenital heart disease about metabolic problems. Uh, sometimes they can come, you know, they can be present together as a syndrome. So what are the skin marks and rashes that you will be worried about in a sick child? Basically, would ask the child whether the rash is itchy or non itchy. First, on basis of that, we could assess. And what are you thinking? It's itchy. What are you thinking about? Uh, h either It could be exposure to something and irritant Okay. Okay. What else? Uh, Okay, so we have particular rush. We have pepper. We have nonblanching rush because, uh, that can, you know, indicate manager cockle sepsis. It can indicate I t p It can indicate malignancy. It can include indicate d i c. It can indicate nonaccidental injury. So that's one. Yeah, which is so also the spreading of the rash, whether the rash is just in 11 location or many location and the rash size, whether it's an annual a ring size, whether it could be, like, kind of thick bone, just tick bite or something. Okay. So without us. So the most important thing, as you said, is when did the rush and started is it spreading? So if you have a family noted that the child had particular and when you know, when they arrived just on the way to the hospital, they spreading that you will, you will be worried. Obviously. Meningococcus location, location of directions, definitely. Give us some example. Uh, some in scarlet fever like that, uh, some rashes is up here from the body trunk. Mm. Okay. So if it's in fact, but it could be a whether the rashes position as is that whether it's scarlet or it, uh, some other rashes, such as the genitals, could also be concerning. Okay, um, so one of the non particular rush that appears in the lower limits associated with HSP, for example, um, so it's very typical, which is, uh, well in pepper. And so that is really important measles, especially if the child's not immunized or there is a problem. And when there is a conflict in an area on conflict and there's interruption of the vaccination, you can see, um, illnesses appearing. So, you know the rash with Koplik spots? It's coming. Um, um, so that's as well can be relevant. Um, what about other skin marks that will be worrying in a sick child? Change in color as well? Uh, it can be, But, you know, in Children, always you have to think about what else? What? Uh, okay. Is there anything on the chat with? No, there's nothing. Whether the rash is hurting or itching, itching or hurting could also be so. The itching rash, I think, which is important in a sick child when you will be like anaphylaxis, because it's like Arctic area rash that It's itching. That is important. One. As you said, if there has been an exposure to a chemical, that's one thing. But skin marks like bruises. Will you not be worried if there are bruises? Yes, Like an ax due to accident or fight. You do trauma, Bluish. Sorry. Some bluish appearance of the screen skin. Do you do some accident or trauma? So what we what I'm trying to say here we are worried about child protection, physical abuse, safeguarding and an accidental injury. Uh, but we have to as well realize that some of the skin marks are birth marks so that we need exposure seeing different Children, making sure you're familiar. And you know which is which. Um, So, uh, if we move on because of the time So this is from the European data why Children die. So this will depend on the age group and the presentation that has been the vaccination immunization have changed the pattern. So, for example, 20 years ago, um, meningococcal sepsis was, you know, one of the leading cause. Now it's not the case because there have been vaccination. But is the vaccination available in each part? Is it interrupted um, and therefore you can see some of the serious infections coming back. Like now. Um, there has been in the refugees camp, uh, cases of diphtheria. While diphtheria vaccination has been global, there has been good coverage in most of the areas. Diphtheria has reasonably disappeared. It's not a common presentation. So people for forget is like how even too sometimes diagnose it. But now it's reappearing because, you know, vulnerable people, disadvantaged people who have not had the vaccination covered for one reason or the other. I'm not talking about those who made the decision for themselves or Children not to have the vaccine that some illnesses are imagined. So when we look at why Children die and, um, in in pediatrics, I stress that that we have different age groups, and because of the different age groups, the presentation can be different. So if you have any unit and who's really unwell, you have to be concerned that there is something maybe congenital, like a congenital heart problem or metabolic. Unborn errors of metabolic is, um or you will be worried about serious substance, postnatal substance, or it's an express. Um, baby was born very, you know, extremely premature. Uh, so these are the main causes that will lead the units to have serious, and this is on time. When you move along the line, you can see that the etiology is changing from congenital anomaly. Respire it to the illnesses infectious illnesses until you develop your immune system and you receive your vaccination to malignancy trauma. CNN's disease, mainly epilepsy. Two um, main limn agency trauma and CNS diseases. And then you can see any young people between the age of 15 and 19. Trauma and the trauma can be road traffic. And they are not careful with putting helmet when they are, for example, cycling or it can be trauma virus, uh, taking behavior with drugs. Um, you know, knife injuries or mental health problems, um, with which is now becoming a like an epidemic. And unfortunately, there's not enough services to support Children and young people, and there are cases of suicide and deliberate self harm. So the etiology is different between different age groups, and you have to familiarize yourself with that because when you are assessing the child, you have to be thinking about what am I dealing with? So if you have a child with 15 year old and the family tells you he has been completely, well, unhealthy. No other problem. And he's a child's comatose in front of you. You have to think about what could be the cause. Did he folded? He enjoyed himself. Did you take, you know, an overdose? Is it a drug? Toxicology? It's not like when you're looking at a seven week, seven days old, baby, you think? Is it substance? Am I dealing with metabolic problem? Is it cardiology? Um, you know, is it You know, you know what's happening? Um, can I see that you know, evidence of, um safeguarding or what's going on. And you cannot just remember them or memorized them just in your head. It's again about exposure and about, you know, as much as possible. Hands on in accident, emergency and acute assessment. Your it's so what are the areas to focus on the area to focus on is about preventing these serious analysis. We can't prevent all of them but early identification of a sick child so that you can prevent the complications and deterioration. And if you have expected death versus unexpected death, so when you say expected death. You have a child with significant congenital anomaly. And you know that the prognosis for this child is poor is one thing. When you have a child who's presenting with sudden infant death and you're thinking about what could be the cause, road traffic accident is a serious, uh, factor as well as mental health. But sometimes you cannot resuscitate the child because there is an agreement as well known in the UK as a respect where there is an agreement that this child, you know, the prognosis is poor. The child is in palliative care, for example, malignancy. Um, there is no further treatment sadly, but there is an agreement between the family and national that this child we know of receivers is at the region. This will require a multiple stability, um, approach and communication between the G p that was visited, the school nurse, the paramedic, the hospital they prosperous. So everybody knows because the last thing you need is someone who doesn't know. And then they found this child and they think it's my duty. I have to perform the CPR. Okay. If you don't have this information, you would feel I have to do it. But if there is this information and the family are aware and there is this agreement, it's in the best interest of the child. Then people have to follow and respect that. We have mentioned briefly about nonaccidental injuries about safeguarding concern. This has to be always at the back of your mind. Always, you cannot see a child or assess a child in any situation. See if the child seriously unwell or not, without making sure you're screening to make sure that there is no safeguarding concerns. So the learning points that Children are more likely to suffer a secondary rather than a primary cardiac problem. The main problem is usually respiratory and hypoxia. Therefore, treating hypoxia is the most important. But obviously treating other problems infant and young Children, respiratory and circulatory anatomy and physiology will affect the etiology and the management. A B C D E approach is the basic for assessment and the basic for management. So as you are assessing, you are treating as well airway. If you can't have to open their way, you can progress to be there's problem in be a problem in C, D and E. So, while you're assessing the child as well. You are managing. So in summary, successful resuscitation from respiratory arrest where there is still our cardiac output is associated with 80 to 90% good quality, long term survival. What we're trying to say here if you don't have a cardiac output, if this child has a prolonged period of respiratory arrest and hypoxia to the extent that affected the cardiac, you know, muscle, the outcome will be very, very poor. Survival from Second Riccardi, respiratory and rest without neurological see equally is considerable less likely, particularly if it happens in pre hospital setting. So identifying the child and making sure that the child is transferred safely to the area where there is the best resuscitation. Sometimes that may not be possible, but people will try the best to make sure the child is is looked after in the right place. So is there any questions? Um, for me, um, there are currently no questions in the child. If anyone do have a question, can I ask? OK, how do we approach a patient or a child who is under a fear like who has been abused but is like trained in a certain way or by a authority. Fickle parents that not to say anything to the chair to the doctors? Well, if the doctor is inspecting like it's more than like an art than a science went to speak to a child as a patient, it depends. How old is the child? If you have either defied that there is a child has something to do or you have concerns about safeguarding. It depends on the setting where you are practicing because in certain areas that can be a protocol and you ask. The parents and the parents are not keen to talk. Then you have to make sure that the parents, um, if they move out and you have the nurse and you speak to the child if the child's still not talking to you. But you have services like social services and you are very worried, then you have to get them involved and get the police and have a multi disciplinary. This is the wide rate. You will not go immediately to that, but you have to have a way of making sure you gather information and the concerns. So if I have seen a child that looks worried and doesn't want to talk. And there are bruises. I'll be very concerned. Uh, I can have a child who's just worried, but it looks very dirty and looked after it's neglected. I will be very worried, Um, and in this case, it will be, um sometimes, you know, if you can't get any information is to seek advice from social services and the police. I will ask, um, if you're a junior doctor, you're the support of your PSA senior colleagues. First of all, because we will ask the family and ask them why. Why this child has got this bruise is what is the cause of the bruise. If you are unable to ask them or they're not, you need to ask them. And if they're not giving you a good, valid point, um, if you have a child who's neglected dirty or a child who's not thriving. I remember we had a child who, the family said the child doesn't eat. The child is vomiting, blah, blah, blah, and the child is losing weight. And when the child was admitted, the child is eating everything. They were eating some paper, so they're so hungry and so they were eating, and this is neglect him. Um, so what I'm trying to say if you have a protocol in place, that's great. If a junior doctor, you have to get your senior colleague. If you're worried about safety, you have to get the safe social service at the police. If you have that protocol in place in your area where you're practicing, what if they have to act on it? But what if the parents are misinformed, such as if a if a child or infant is if the check basic assessment is done and see the child is losing weight like Children are supposed to grow, not shrink. So what if the parents are misinformed regarding the regarding the feeding of the baby, and it could result in the anything if they have some, either by themselves or by there? They have a certain experts who believe the parents believe are the nutritionist experts but are misinformed and results in a, uh, malnutrition of the baby. It could also lead that the parents might get into trouble rather than if they're not the main culprit in it. If they are misinformed, Yeah, so if they are misinformed and their child is admitted. There is a, uh, time for the team to explain to them and increase their awareness and direct them to the right information and explain why the other information was not appropriate. And give them an indication objectively about the intake about the weight about the height, um, and act on the best interest of the child. Hopefully, the parents will understand, would appreciate that they got wrong information and that they will seek information from the right professionals and then that sorted. But if they are not, um, then you will have to go into the safeguarding assessment, because then the child will be under a risk. But I would suggest that this is a very important discussion. Should be in the safeguarding sort of, um, situation or safeguarding training. And I'm not sure if Sharon is here whether there is a safeguarding a lecture or not. She's not here. But I can ask her. Yeah, please. Um, if you ask her because this is I hope that there is a safeguarding, um, child protection assessment, because that's a complete, important topic. Okay, I have another question. Prior to your lecture, we had a neuro neurology lecture consultant regarding epilepsy. And it is said that, uh, gratification disorder is one of the things that parents don't know. And it is, uh, said that we should approach the patient and the parent safely and while saying it, not the not not to use the word masturbation, because the kids, the child doesn't know it, but the parent knows it. So by words, we have to be very careful while approaching the parents to explaining them. So in this settlement, we are talking about acute illnesses and, uh, saving lives. I think, um, I would talk about safety approaching a different way. I'm talking about safety approach. If you are dealing with the child in a road traffic accident that you have to be safe yourself so that you can save the child. Um, but about the communication, what you're talking about. Obviously you have to be aware about the culture and the communication where you are practicing and whether you would like to express all of the information in front of the child or you want to express it separately in a room in the family with the presence of a nurse and document that clearly in your notes. So when it's, uh, gratification to sort of like some of the people or it is suggested that the parents have to teach their Children about privacy, is it like, does it work in that? Well, yeah, I think this is out of the limit of this topic. Because this topic is about resuscitation of a sick child. That may die. But the other thing about behavior, um, that will be in a different lecture as well. So I think Hannah, if you're taking these notes, that will be useful. Sorry if you're taking notes, too. Sure about the points that have been mentioned because this is part of behavior and community, so that should be lectured in a different setting about safeguarding should be another lecture. So if you're taking notes of these questions because then yeah, for the time, you know, have the timetable for these topics. Sure, I'll pass it along, although I think we've fully booked until the end of the online medical school in the 20th of December. But I will ask about the safeguarding if she can give a lecture on that possibility. There is a question about behavior as Well, okay. I'll mention that you asked about the This is part of behavior and development. The last question? Yeah, sure. Is there any question in links to, uh, a B C D approach identifying the sick child resuscitation? Because I'm aware that, um, there's only five minutes left. Is there anything written in the chat box? Or if not, then, um, you can have four minutes. Early break. Sure. You had a lot of lectures today. There's nothing in the chair right now. If anyone wants to add something quickly, um, as a thank you. Thank you. Thank you for attending. So the next session, I don't think it's next week is the week after I'm going to the river simulation case based on identifying the sick child on this lecture and as well, I will mention briefly about the allergic marsh. Thank you very much for the report. And, uh, yeah, everybody, uh, if you have any questions that you would like to send, um, to, um you know the organizers. I'm happy to answer. Thank you very much, Doctor. Um, and since we have a few minutes left, if you haven't done the feedback for me yet Please do that now. Um, I've also posted the link to the new WhatsApp Group for any updates about the online medical school. Um, and I will put on these are difficult ones. If you could please confirm that you've done the feedback in the chat and then I'll post a certificate and then we're done for the day. We've had a very long day of lectures today. Okay, then. Bye bye. I will leave now. Bye. Thank you very much.