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Identifying the sick child (1), Dr Caroline Delahunty



This on-demand teaching session will provide medical professionals with the tools they need to safely and systematically assess a sick child. Led by a retired consultant pediatrician, Caroline Della Hunty, topics covered will include the mechanics of assessing the airway, breathing, circulation, disability, and glucose levels. Participants will learn the signs to look for in order to treat life-threatening airway concerns before progressing to the assessment, and will receive useful tips on the physiological parameters and behaviors of different age groups. With the insight gained, attendees will be better prepared to save lives in the field.
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Learning objectives

learning objectives: 1. Understand the ABCD approach to the recognition and assessment of the sick child. 2. Be able to assess the patency of the airway, breathing, heart rate and circulation of a sick child. 3. Understand the specific physiological parameters and behaviors that are particular to children that require consideration. 4. Be able to identify signs of hypoxia. 5. Understand the importance of checking a glucose level in young children when assessing the degree of sickness.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

If you want. Good afternoon, everyone. My name is Caroline Della Hunty. I'm a retired consultant, pediatrician actually. Um, but only just I'm stepping in for Sarah who's been unable to deliver a lecture this afternoon. So I I've been told the title is the Recognition and the Assessment of the sick child. And I'm going to take you through how to recognize and I thought we'd run through a couple of scenarios. I'm sorry if it is repetition of anything you've been delivered before, but I am stepping in at short notice, but there you go. So I think the important thing is that we're going, we have to learn a systematic approach to the recognition and assessment of the sick child. We know that this saves lives. So if everyone does the same thing and you are working as a team, the system is calmer, it's systematic and you should not miss anything with the tools that we're going to take you through. So it is the same as the systems you use in adult assessment. But I do want to emphasize that Children are not small adults and that we need to think about the age and stage of the child. It is very different to assessing a one year old, to assessing a baby, a newborn baby and to assess in a 10 year old, they have different physiological parameters and different behaviors which help you. Ok. So first thing we're always going to do in any assessment is the ABC DE approach. And I think the important thing is after we assess a being airway, we treat any concerns about the airway before you go on to assess B. So if there are life threatening concerns at any stage, you need to assess, you need to treat it. I think in reality, although I'm emphasizing it as S ABC DE in turn, I think because of the visual and clinical skills that you have and your, your ability as you progress through your medical career to interpret very quickly, you're often doing a more holistic approach to this, but we always start with airway is the airway patent. And if you don't deal with an abstracted airway, obviously, you're going to become progressively hypoxic, have breathing difficulties and you're not going to be able to sort out breathing until you've sorted out the airway. So you deal with what you find before you move on. So I'm going to take, actually, let's make this more interactive as we're quite a small group. Does anybody want to shout out the things that you're looking for in the airway? Uh Patency of the airway such as it epithets, there is not edema or no foreign body obstruction or no obstruction of the airway itself? Ok. Yeah, absolutely. You're going to be thinking about the history as the child coming in with a history of choking foreign body aspiration you're going to be. But I think the most important thing is to look at the child, isn't it? Are they able to talk? Are they able to cough or are they silent? So, absolutely. Ok. So airway basic life support tells you to look, listen and feel. Now in the clinical situation, you don't always do the feeling. It's only if actually, I'm not sure this airway is patent, will you then put your ear to near the airway and can you hear or feel breathing? But really what you're doing is you're looking overall. So if it's clear and patent, your child should be talking, um you know, able to respond, able to talk, able to cry. A baby crying has a clear airway. Unless when you listen to the noise, it doesn't sound right. So if they're coughing, they may be in a choking attack, I appreciate or it may be cough as a result of an intercurrent infectious illness. So, but coughing suggests that airway still has some patency, Stridor, that inspiratory sound that we hear will suggest that there is an airway problem. So if on breathing in, you have a harsh inspiratory sound, you have a partial occlusion of the airway. So, Stridor suggests you have an airway problem. If the airway is silent, you can't hear it. You can't, when you listen, hear any breath sounds, moving into the chest and you can't feel any air. That's obviously your extreme scenario. Um, the silent airway is a very critical emergency, but I think the treatment is always give oxygen if in doubt, give oxygen and secure the airway, if you think it is a critical airway, so secure the airway if needed, but it is never wrong. And it is always right to give oxygen s quite see, but I thought it would be helpful for us to take the columns in turn. So we've talked a little bit about airway and then we're then going to go on to think about breathing. And what do we look for? The beauty of a child is they have a compliant chest. So in some ways, they give us more respiratory signs, they can show the effort of breathing. First of all, um you know, are they exaggerating with the use of the accessory accessory muscles, abdominal muscles, you know, babies use abdominal musculature to breathe. Whereas adults don't tend to do that so much. But babies do, they breathe with their abdominal muscles, you know, but all Children will if needed, use their sterno cli a mastoid, their neck muscles in an infant. We see that used as head bobbing the head comes forward and back. The head bob is quite dramatic. Babies head bob as well. Whereas adults don't tend to head bob, but you'll be seeing the neck muscles go in. We will see because the compliant chest, we can see sternal recession in the end fives. We can see intercostal recession and we can see a tracheal tug all because our cartilage is very soft and there's a lot of pliancy around the chest. So there's a lot more visual signs that you can look for if the baby is grunting or if a child is grunting is telling you they are trying to give themselves CPAP right? Continuous positive airway pressure. They're trying to improve their alveolar atelectasis, their alveolar recruitment by grunting, they breathe in against a forced epiglottis to try to improve alveolar recruitment. We're going to look at the respiratory rate and the pattern of breathing. Um I think respiratory rate can be difficult because you need to know the normal ranges for each age and stage of a child. So a baby, for example, will breathe 40 to 60 breaths per minute. Whereas an older child is the same as an adult, a 10 year old, an eight year old will be 20 breaths per minute and the age ranges in between are different. I'm going to show you a chart in a minute. Can anyone I've got rhythm in there and I questioned it myself, but why have I put rhythm? I am thinking very much of a younger child, a two month old what can they do with their breathing rate? What do they do? That's different to adults. They can have pauses, they can have apneas. So when you're looking at a child, you want to make sure they're not pausing. And an apneic event is defined, defined as a pause of 20 seconds. It's quite long. So it's very different periodic respiration where you will speed up, you will slow down. But if you stop for 20 seconds and have an apneic event and we see it in the babies coming in, then that's obviously very significant. We're going to think with our airway and our breathing about the noises we hear. Do we hear an inspiratory noise? Stridor? Do we hear an expiratory? Wheeze? And obviously you're going to listen with your stethoscope and auscultate. What do you hear? Are you hearing asymmetry of noise suggesting that there's a pneumothorax or a hemorrhage? One side? Are you hearing added bronchial breathing or preparations? So you're going to be thinking through what you're hearing in your airway and breathing assessment? Skin color is there because you're going to be thinking about hypoxia causing cyanosis or pallor. Ok. So color is part of a breathing assessment. Are they blue or are they pink and then moving? And next, I'm moving down this circulation column. So we've done A and B, we move on to C OK. ABC circulation. The first thing you're going to do is listen with your stethoscope if you have one and can you hear a heart rate? Ok. And the easiest way to assess it the heart rate, um I appreciate we all feel the pulse for the pulse volume but is to listen the most accurate way is auscultation. Ok. Is there a heart rate? Are you in asystole? Are you slow? Are you fast then feel, can you feel the pulses? So they do, do they have a cardiac output? Right? This is very much adult term, isn't it? Is there a cardiac output? Can you feel a pulse volume? And if so, is it normal? Is it of good volume or is it thready? You're then going to go and assess circulation further by doing capillary refill where you press on the sternum, um probably around about the sternal notch. You're going to press for five seconds until you see the skin go pale, then you're going to take your fingers off and you are going to count how long it takes for the color to reappear and a capillary refill of certainly greater than five seconds. Like I would worry if they're greater if they're at four actually, but certainly greater than five seconds is of significant concern. Adults lay an emphasis on central and peripheral capillary refill that doesn't quite work in babies. So again, it's the age and stage of the child because babies have a lot of autonomic vasomotor instability and they will peripherally vasoconstrict if they're unwell very easily. But certainly after the baby phase, it's a good idea to do central and peripheral, we do skin temperature. So again, if there's a difference, if you've got this, the equipment to do it, if you can do central temperature, a rectal temperature and a peripheral temperature, and if there's a discrepancy of greater than two degrees, it would suggest you've got poor perfusion. But again, look at the skin, are they pale? And are they mottled? Ok. Moving on to disability, we're going to think about the conscious level and the behavior of the child. I've added in behavior into this column because if they're playing on mum's lap, you know, they're not that they've got appropriate consciousness, they're engaged in the Troy. And even if it's just very subtle play play, even if it's just cuddling their blanket or, you know, looking at mum, what is their interaction with their mother or their dad? How are they behaving and what is their conscious level? But obviously I'm gonna, there's another slide where I talk about how we can assess conscious level if we do have concerns, but your eyeball is, are they behaving or do they appear to be responding appropriately? You're going to be looking at the posture of the child. You know, if they're lying in an extended tonic posture, decorticate, decerebrate, then that's very important. We do look at the pupils as part of our disability assessment in your ABC D approach. You're going to shine a light on the pupil pupils and make sure they're equal and reactive. You're also going to do a glucose. Children are much more and particularly a young child under the age of five are much more susceptible to having hypoglycemia. They do not have the glycogenolysis stores and the lipid breakdown stores that adults have and babies certainly, if they're unwell, are very susceptible to go in hypoglycemia. And remember, hyperglycemia causes brain cell death and causes damage. You don't want to miss it. That, that having assessed your ABC D, you're then going to go on to e exposure, which is more about trying to find the cause uh of the problem actually. So do they have a fever? Are they septic? Do they have a rash to support a diagnosis of infection? Are they bruised? Is there obvious trauma? So it's all about exposing and looking for the cause? Oh, this always happens that my slides will stick after a while. When I've spent too long on a slide, it sticks. Right. I may have to stop screen sharing and re share again. Bear with me. All right. Take your time. Ok. I'm going to go back. 20. Right. Ok. So this is a slide showing you the, the fact that respiratory rate varies as we progress through childhood in a less than one year old, it's 30 to 40 less than three months. I would accept 40 to 60. Um But 1 to 2, it's 25 to 35 2 to 5. It drops slightly and we would accept up to 30. But it, it's really all about looking at the child and looking at what else is going on. So if they've just got a tachy near, let's say you've got a five year old whose respiratory rate is 30 but they may be a bit hot which will drive that up. But it's what else is going on in the chest? Is there any accessory muscle usage? Is there any intercostal recession? Is there color good? Does the chest sound? Ok. So it's taken into the whole picture. So I wouldn't get too worried about numbers actually because I think there is a holistic assessment that you're doing, but greater than twe age of 12, you should be back into your adult LEV levels. Ok. So we're still on breathing. We're now going to talk about what we hear when we listen to the chest and where that may take us. So, ok, once we come into scenarios, you guys are gonna be answering the questions. So if you listen to the chest and you hear an inspiratory sound on breathing in, that is stridor quite often. You should be able to auscultate. You hear it without auscultation, you should be able to hear it just while you're chatting and assessing the child. It suggests upper airway obstruction. There's lots of things that can cause that there is a much bigger list than what we've got here of croup and foreign body. And we're gonna go into a scenario of an upper airway obstruction. We're going to think about, if we hear wheeze and expiratory sound, we're going to think about lower airway obstruction and reactive airway disease. So, asthma again, it can actually be a foreign body and sensitization of the airways though. But with that, it should be a fixed localized wheeze. If you've got a foreign body, it shouldn't be widespread in a pneumonic a viral process causing wheeze or an asthma attack. It should be widespread. Localization suggests you've got inhalation of the foreign body, especially if it's the right lung because the right main bronchus is smaller and it sorry, branches off first and you're more likely to aspirate down. It's not smaller, that's wrong, but it branches higher up and aspiration tends to take place on the right side. If you've got crackles, crepitations, that means you've got lung parenchymal disease. You may have fluid that may be edema. It may be exudate, transudate. It may be mucus, it may be blood and hemorrhage. You need to think about all the causes of crepitations. If you're grunting that baby, it's usually AAA baby. Actually, they're trying to recruit alveoli and restore their functional residual capacity. So you're going to be thinking about pneumonia. Apparently, Children who have gone through drowning are, are being pulled from water will often grunt as well as they try to clear the fluid and open up their airways. If you've got asymmetry on auscultation of the chest, it's going to make you think. Do you have a pneumothorax which needs to be treated that should go along with the tracheal deviation? Ok. So, asymmetry, think about the position of the trachea. It's not quite as easy in Children actually as in adults to assess the position of the trachea because I think the space just isn't as big. But you would think about is there a tracheal deviation? But you need to think about pleural fluid occupying that space consolidation if you can only hear breathing on one side, but if you've got consolidation, you'd hope you would actually get bronchial breathing to take you very clinically. But think about your pneumothorax. Think about your hemothorax. Good. OK. Let's move back on to c I appreciate a lot of this is reiterating that table, but I think it's good to take it in sections. So we're going to think about our rate. Are we tachycardic or are we bradycardic? Bradycardia? Remember is preterminal unless you've got heart block, but it's a preterminal late sign, they are perry arrests. You want to think about your delayed capillary refill of greater than four seconds. Some textbooks will say five seconds again, hypotension is a late sign and BP correlates with age and height in particular actually. So, but there are charts and wherever you're working, you should be able to access the chart to know if that BP is normal for the age of your child. The treatment of a circulatory failure or the first line treatment would be to give a fluid bolus of 20 mils per kilo of normal saline to support that. The treatment of A and B is to give oxygen and then target the specific cause P. So it's a conscious state assessment. We use a pneumonic A nomogram called AU A VPU A being alert. Are they appropriate? Are they responding? Are they alert? V is response to voice? So you can get them to answer but then they'll be sleepy again. So lethargic, when you ask them a question, you can get them to respond by vocal stimulation. Pee is responding to pain, you have to hurt them to get them to respond, to move, to open their eyes, to cry. And we use in Children, we tend to very much either press on the sternum or we press supraorbital. We'll press above the eyes. So very similar to adults and you is their unconscious. They don't respond to any attempt you have made. So as who, OK, let's move on to a six year old and some scenarios. So we have a six year old who was brought to hospital with a harsh cough and breathing difficulties. There is a history of fever and sore throat, right? I'm gonna ask someone to shout out or write in the chart. What are your actions OK, as that, you have your hand raised. Go ahead, please. Uh Yes. Uh, first we have to ask, uh, since how long this has been happening with the, that and we might have to check whether these, uh, events are not recent, like asking the history properly. We might also ask, what are the other behaviors as well? Is it just the coughing or something else or is it coughing while something comes into contact or at a certain event or a certain time? We might have to check the patency of the airways. Well, well, whether the patient is sino or not, whether the complain is mostly of the cough. So we might also have to give her oxygen therapy as well. And in this case for right now to be on a safer side of antibiotics, me maybe. Oh, ok. No, I, that's great. Thank you. So, I'm not sure I'd rush to antibiotics, but just to go back over what you said, you're going to take a short history, try to find out and while you're visually assessing the child as well, you're going to take a history. Find out how long has it been going on for. Is there any possibility a foreign body? You know, but you've got this history of fever and sore throat. So it's unlikely. But you're going to find out what's been going on, who else had it in the house and, you know, are they able to talk how are they? But you're going to be thinking about what does that airway sound like? You know, can the child talk to you but definitely give oxygen. It's never wrong to give oxygen. So I think giving oxygen is a good idea. Um if you're in a position to put a pulse of symmetry, which I haven't mentioned we would always if we can without causing distress, but I think you're going to be looking at the behavior and the alertness of the child as well. So you go, it's all down to assess history and assessment, isn't it? So you talked about the history and then you talked about assessing the airway um particularly as you've got this history of stride or it's suggesting you've got an airway problem, you know, but by looking at the color of the child, are they cyano, you're going to get a feel for how much air they're moving as well. But looking at the posture, what things in maybe postures? No, I don't think posture is the wrong word actually. What things looking at the child would you? So it's a six year old. What would you be reassured by in their behavior? And just the Visu as you visualize this child, what things in particular would reassure you or what things would concern you then as another way gone, shout out either way, the position like where the child is leaning forward or just standing or sitting upright or it's just lying down. So we might have to estimate that when the, when, when the child feels comfortable, like, whether it's leaning or straight up or lying up. Yeah. I didn't quite catch everything you said there, but absolutely the posture of the child, the position of the child. So you're gonna look for things. Like, are they sitting forward? People say that in epiglottitis, for example, or severe tracheitis, a child sits like a tripod. they're leaning forward because that is the easiest way for them to breathe. If you can't breathe yourself, you sit up, ok. If you're lying down, your breathing is easier. So, a child that is sitting up and certainly a child that's propping themselves forward, they're trying to make their breathing easier. It's easier to breathe, sitting up than lying down. You're going to look if they're drooling, are they able to swallow saliva or, you know, if they're drooling, they can't swallow. So that airway and I appreciate you don't swallow into your airway, but you swallow into your esophagus, which is adjacent to the airway. So if the airway is swollen and semi obstructing the esophagus, you're not going to be able to swallow and you're going to get cooling of secretions and you get drooling and excess salivation. So that's actually a very critical sign as well. So the positioning, the color are they able to talk and drooling and saliva. Let's move on. This is our child. So when we look at this child. I see a child that's alert. So that's good. Right. They're not unconscious. They're able to maintain some patency of that airway to keep themselves alert, to keep oxygen flowing into that brain. Ok. This child is able to hold the mask, let's pretend it's just oxygen at the moment and it's not treatment. Um, they're upright, aren't they? They're sitting up, he's quite pale. So I think he is compensating. Um, and I was hoping this was going to show that his trachea is slightly pulled in. It doesn't really come through, but that's what I was trying to show slightly. But he is someone who can sit up and hold a mask and is neurologically appropriate for us. So I'm gonna go on to some differentials. Actually, this is quite a big slide. Maybe I should have put this slightly further on. So our child had Stridor and a cough with a history of sore throat. Do you know I'm gonna miss, I'm gonna skip. No, I'm not. Right. Ok. We're gonna have to go with the slides. Ok. So these are our differentials like in the UK croup is, is by far the most common that will not be the case worldwide. So in croup, which is viral triggered, what we find is we get a lot of admissions actually because it's quite scary for the parents because it sounds very harsh. The child is apologies for that. Do you can continue? I've meet them. Ok. The child is struggling to breathe. So, so what we tend to do for the treatment is steroids as an anti inflammatory we use and this may vary around the world cause I believe prednisoLONE is cheaper, we use oral dexamethasone but because it's quicker acting, but oral prednisoLONE, if that's what you have works as well. But in a slightly longer time frame, it will take two hours to work. Whereas oral dex will work within 30 minutes. It's really quite dramatic. If we have access to nebulizers, you can consider nebulized, inhaled steroids, budesonide. But if it's a severe case and you think you're about to li be lifethreatening and that if you, you don't open this airway quickly, adrenaline is im adrenaline is the, the way to go. So think about these things if you have a neurologically abnormal child or a baby and there's excessive secretions and doubling, we may consider suctioning if they can't clear their airway themselves. I think the important differentials I want to talk about actually are if you've got a softer Stridor is actually of more concern because there's less air moving. So if the Stridor is loud, you're actually moving a lot of air. If the Stridor is very soft, that worries me more because it's a more swollen airway with less air being shifted. So, do you ever get a question in an exam? Um is soft Stridor or more significant and serious than Har Stridor? The answer is yes. Ok. So if you've got drooling, they can't swallow. And if they're fever and they look ill tends to be that it's bacterial infection and to go back to, I think it was as a, that, that gave some answers earlier on you said IV antibiotics. I'm going to slightly apologize actually because I think in the UK, because it tends to be more viral because of the environment we're working in, We don't tend to rush down the IV Antibiotic line. But I appreciate in different parts of the world. If you, you have a higher prevalence of bacterial airway infection, you may well do as your standard practice. So my apologies. But if we think it's bacterial, we absolutely would want to give IV antibiotics. But we may want to actually have our anesthetic colleagues doing an assessment with us at the same time. Do they want to secure the airway? Because causing additional distress to the child can, can precipitate obstruction of the airway, which is why we never look if we suspect epiglottitis, we don't have a look with the tongue depressor and the light because we take them to theater very quickly to do an assessment in a controlled airway environment. But I, I appreciate your situations may be different elsewhere. So we think about bacterial tracheitis or epiglottitis. I've got a slide coming up on that. We'll think about sudden on if we have sudden onset stride over with a history of inhalation. It's a foreign body and we may need to remove that if we're known to be allergic to, for example, nuts and we've had to sudden ingestion and then we get stridor. We actually think anaphylaxis and im adrenaline. So, if it's a known allergy, the treatment is adrenaline, we don't bother with re steroid steroids. We go to adrenaline. Ok? I can't see the top it slide. Uh OK. So the this side is talking about epiglottitis. I'm sorry, I'm not sure it's titled, but this should be reading Epiglottitis. Ok. Uh I'm just gonna close chat actually, so I can see. Right. Ok. So epiglottitis is much more common in 4 to 6 year olds. We have in the UK, we have a population that's vaccinated against haemophilus influenza which has dramatically reduced the incidence of this. Um, but 10% still get it even though they're vaccinated. So we still see it. The important thing is they're slightly different. They are drooling, they are tripoding, they are sicker, they look sick, they've got respiratory distress and we, we don't have a look with the tongue depressor. As I've just said, we would actually take them depending on how severe it is. If we think they would tolerate IV antibiotics and oxygen on the ward, that's fine. If we think they're very severe, we would take them across the theater so we can do it all in a controlled environment with the anesthetist. Secure, the sorry the airways. I've got some pictures on the side of a very inflamed looking epiglottis. It's supposed to look like very swollen, well, a very swollen vocal cords, you can't see them clearly. They're edematous. And if you did an x-ray, if you're in a country that would still advocate x-rays to differentiate, you see what we call the thumb sign. So up the top here, you could actually, you would actually see the thumb, almost the thumb fringe of the epiglottis. You can't normally see it on x-ray. So if you can see it and you've got a thumb sign and the likelihood is that you've got um gosh, I just, oh, this is frozen again, right? OK. No, it's not. I wanted to make this more universal and I've put a slide in on diphtheria again. We very rarely see it. But you, you guys with your expertise will see it much more and we'll be very aware of that gray membrane when you look at the back of the throat and that it can be rapidly toxin, progressive and that you need to secure this airway in addition to giving your penicillin or Erythromycin. If I see if I saw diphtheria, we would intubate and ventilate that child. Any questions about that scenario before we move on, going to run through another scenario, I appreciate its course to, but we, we just will. OK. So this is a four week old who's presenting to you with a history of poor feeding, lethargy and unconsoled crying. So it vague history isn't it? But hasn't cared. Well, for 24 hours for speed, I'm gonna take you through that. You're going to do your ABC DE assessment. So as your systematic approach to this child, the airway there is no stridor or cough, it appears clear the baby is able to cry. So crying is a good sign, shift in air from an airway point of view, child is breathing. But when you look, the child is grunting, the child has nasal flaring has recession, intercostal and subcostal. And when you listen, you hear crepitations, you hear crackles and when you count the respiratory rate, the rate is 65. I've put a statement, apneas are a possibility in this age group. So look for them. Is the baby pausing for 20 seconds. I'm going to ask. So what, what would be your action here? What's the first thing you're going to do? Uh gave oxygen like oxygen supply itself. Yeah, give oxygen and if you have access to a pulse oximetry, so you're measuring the degree of hypoxia, put a pulse oximeter on but give your baby oxygen. So you have given some breathing support while you go on to assess the circulation. You find the baby is tachycardic at 1 70. I would expect 1 50 in this age group, baby's pale mottled. Not sure what I think about being pale and muffled because they've got such poor vasomotor instability. It can be a false sign of and that they're not shot. But when I look at my central capillary refill, it's five seconds. So that is delayed. So again, what would be your action here? You might also take a x-ray as well if possible, that would be an investigation. But first of all, I'm going to deal with C I'm going to deal with circulation. So I would think about giving this baby an intravenous fluid bolus of 20 mils per kilo to give them some circulatory support. Ok. But we certainly will as part of our investigations on our secondary assessment, be doing an x-ray then moving on to disability. I I would also get my going back to see, sorry, I would give her fluid bolus, but I would ask the nursing team to get a BP. If it's possible if we have the facilities moving on to disability, the child is lethargic, sleepy but will awaken if you can. And I appreciate you tend to sort of slightly stimulate the child. They don't necessarily awaken to voice, but they will awaken. The pupils are equal and reactive to light. There's no asymmetry, the tone and the fontanelle, the tone's floppy, but the fontanelle is normal, but I would always do a blood glucose as part of any disability screening. We used to say ABCD EF and the DEF is don't ever forget glucose. Um So and I find that this baby has a low sugar. So I'm going to treat it by giving an intravenous glucose bolus because that could reverse my lethargy. You're then going to go on and do your fever and your full examination, uh measure temperature. Ok. Looking at differential diagnosis, I'm sorry, I'm rushing on, but we're a little short of time. Uh You mentioned chest x-ray. So absolutely, your differential diagnosis here because you had localizing babies are difficult actually because even a meningitis will present with tachypnea. But you had a very clear localization, you know, and a metabolic acidosis can give you that grunting. They grunt to compensate for that metabolic acidosis, but you localized your respiratory signs. We said we had crepitations. So I I do think the top of our list here is that we have a respiratory infection. We're thinking, do we have a pneumonia? Um Do we have infection? Are we sep tomate because it felt more than just a pneumonia? It affected our cardiovascular system. So, is this true sepsis always in your differential? You're only four weeks. What did I say? Four weeks old, you could have cardiac failure presenting for the first time your pulmonary pressures may have dropped. You may have a duct dependent lesion even. So you could be thinking, are we in heart failure with diuretic? And we could be thinking about viral infection and bronchiolitis. But again, it's quite extreme, isn't it? If you've got cardiovascular decompensation? I think top of your list is pneumonia and sepsis investigations. A chest x-ray, what does it tell us? We would think about the full blood count, the blood culture, the glucose, the electrolytes would do a blood gas. But the one of the problems with babies is they don't, they're very good carb dioxide at clearing carbon dioxide. So they don't put their blood gas off until they're almost at the point where they need ventilating. So don't be falsely reassured by a normal blood gas on how sick your baby is. It's just, it's a marker but nothing else. We'd think about respiratory swabs and viral screen before I go on to the next slide. Does someone want to shout out what they think is the core likely bacteria. We could be dealing with staph or strip. Yeah. So you're still in the age range of group B streptococcus. I appreciate it's becoming late onset. But group B streptococcus is really at the top of that list pneumococcus, streptococcal pneumonia, staphylococcus, aureus, and think about listeria as well. Um I don't know how prevalent it is in different parts of the world, but we certainly see listeria and we cover for it by giving intravenous amoxicillin as opposed to just IV penicillin and gentamicin. We would give amoxicillin and gentamicin as our first line in this age group. So that we have some listeria cover, we cover our staph aureus with gentamicin. And until we prove what the organism is, I'm going to conclude here by saying the conclusion is a systematic ABC DE approach. It saves lives. I think it's important to keep calm. Ok. And just if you, if you don't know what to do, think ABC DE and that just keeps you moving as opposed to seeing a baby who's obviously sick and panicking. Keep going with your ABC DE and then you need to keep reassessing. I haven't been emphasizing in the reassessment. So the child with Stridor having given the treatment that nebulized gen my oral dexamethasone, I need to go back to make sure it's worked. So I need to reassess after the nebulizer. Are they better? Ok. So you always reassess. So the baby with the breathing difficulties, we've given oxygen, we've given our fluid bolus, you're going to go back and reassess. Are they still maintaining their airway? Are they still able to cope with the oxygen? Is their color improving? And then, you know, has the circulation improved with the fluid bolus? Any questions? I don't see no questions popping up in the chart doctor. It seemed like it was a very clear, straightforward lecture. I really do. Thank you for the lecture and I thank everyone for attending. It was such a pleasure to have you today. And um if no one else has any more questions, do you wanna say anything else, doctor? No, I'm happy. No. Lovely. Well, I can wish you a lovely evening and I hope you have a lovely evening to you. And everyone here in this, we've got one question. We've got one question here. Sorry. Just the last minute it says, please. What is the diagnosis of the first patient? Ok. So that in that child with the harsh cough and the sore throat, it was viral croup. So which is probably our most common airway presentation. So our treatment would be oxygen then oral dexamethasone. So an oral steroid, if you don't have dexamethasone, you can give prednisoLONE, but it takes longer to work and also nebulized budesonide if they can tolerate it, the nebulizer that helps as well. So oral dexamethasone, we tend to give two doses 12 hours apart and they respond very quickly. Actually, very few of them with a viral infection will go on to require intubation. So it's normal and it's normally adenovirus actually. So it, but it can be any virus, viral croppers in um per influenza. Yeah, it can be per influenzas. It's a viral group. Any of any of the viruses often seasonal. We see it quite a bit in September actually over here. Um It tends to peak as some of the viruses hit the Children. Ok. I think that's, that's clear. Thank you very much again, doctor. And I hope you have a lovely evening. Ok. Thank you. Always have a hand up. Hang on. Oh, there's another. No, is a clap. There's a point of appreciation. Thank you very much, doctor. OK. Thank you. All right. You too. Bye bye. Have a lovely evening. Bye everyone. Look after yourselves. You too.