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Recognition of the sick child

Dr Tim Newson Consultant Paediatrician Sub Dean William Harvey Hospital Kings Students Guys, St Thomas' and Kings Medical School. Director of Medical Education William Harvey Hospital St Georges Grenada International Medical School. Recognition of the sick child. www.kssahsn.net/safety.

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Recognition of the sick child

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  1. Dr Tim NewsonConsultant PaediatricianSub Dean William Harvey Hospital Kings Students Guys, St Thomas' and Kings Medical School. Director of Medical Education William Harvey Hospital St Georges Grenada International Medical School Recognition of the sick child www.kssahsn.net/safety

  2. Deaths in Childhood in UK • Perinatal • Congenital abnormalities • Sudden infant death syndrome • Infection/Respiratory • Trauma/Poisoning/Abuse • Cancer • Neurological : Epilepsy & Developmental disorders • Risk behaviours : suicide psychoactive substances

  3. Main findings: Issues with recognition and management of the seriously illness in children Factors: • Care in non paediatric units • Failure to take history and examine • Inadequate observation • Failure to anticipate and recognise complications • Failure to follow national guidelines • Errors by very junior unsupervised staff • Parents over reassured

  4. Category of Admissions to HDU [n=84]

  5. CASE • 3 year old short history of fever shaking & generally unwell • GP triage: high temp looks flushed no rash unwell child [inadequate Hx examination & communication] • A+E Nurse Review: Lethargic but rousable,Temp 39 oC HR 170 resp rate 36 /min, sats 94% in air awaited Dr review.[ identified abnormal parameters but no recognition of importance] • 2 hours later Temp 38.4 HR 172 RR38/min BP 112/50 sats 94% in air small pinprick rash on abdomen. Junior Dr review :sleepy,rousable, no neck stiffness or photophobia, heart rate 171 no rash but few chickenpox scars. Sent home minimal advice.[ inadequate assessment , lack of recognition of abnormal parameters no senior input inadequate discharge information].

  6. OUTCOME : child died 12 hours later of meningococcal septacaemia

  7. Recognise severe sepsis If suspected or proven infection AND any 2 of : Core Temp >38.5 or <36 oC Inappropriate tachycardia Altered mental state Reduced peripheral perfusion Sepsis 6 within the hour Give high flow oxygen Obtain IV IO access and take bloods [culture, glucose, gas. fbc,clotting,lactate.U&E’s LFTs CRP PCR] Consider Fluid resuscitation 20ml/kg 0.9% saline Involve senior clinicians and specialists early Consider inotropic support early [after 40 ml/kg fluids] GOLDEN HOUR: SEPTIC SHOCK –EARLY EFFECTIVE TREATMENT SAVES LIFES

  8. Paediatric Sepsis 6

  9. 25-30% [3.5 million] of all A+E attendees /year are children Increase emergency admissions 18% Shortage GP out of hours, PAU’s, Senior input at peak hours Child protection High A+E attendances: febrile children

  10. Spotting the sick child

  11. Why are Children Different ? • Size : 1-10 years- weight kg = 2 x [age +4] Broselow tape relate weight to height • Body proportions: BSA head 19% at birth to 9 % at 15 years • Airway : narrow nostrils, large tongue, compressible floor of mouth, high anterior larynx • Breathing : upper and lower airways small; resistance =1/4th power of radius; diaphragm. • Circulation :

  12. Why Children Different? • Infection: meningitis, septacaemia, UTI • neonatal period : Group B Streptococcus, E Coli • 2 months to 12 months : relatively immune deficient [falling maternal IgG and own immune system immature] streptococcus pneumoniae, meningococcus, haemophilus influenza • 1-5 years • 5-12years

  13. Recognition of the Sick Child • Risk Factors Age: young age Abnormal physiological parameters eg tachycardia Rapid Deterioration: children can deteriorate quickly with certain conditions eg meningococcal septacaemia so early recognition and RX essential. Non Accidental Injury : with all injuries be aware. Consider in head injury, bruising,delay in presentation, history unclear or not explain injuries.

  14. Children get frightened : increase resp rate ,heart rate, quiet. Child friendly: toys, pictures, stickers, bubbles [distraction] Language: picture rather than chest X Ray Paediatric trained staff “See it from the child point of view” Environment/communication

  15. Recognition of the seriously ill child is based on assessment of: • Airway (with c-spine consideration in trauma) • Breathing • Circulation • Disability (mental status) • Exposure

  16. Airway • Look, listen, feel. • Can they speak / cry? [children can get frightened] • No air movement : airway opening manoeuvre • Noises eg. Stridor?

  17. Respiratory Failure Effort of Breathing • respiratory rate • recession: accessory muscle use, infant: nasal flaring,head bobbing, subcostal recession,tracheal tug • inspiratory/expiratory noises: wheeze, grunting

  18. Age years <1 1-2 2-5 5-12 >12 Resp rate breaths/min 30-40 25-35 25-30 20-25 15-20 Respiratory rate by age

  19. Respiratory Failure Effectiveness of Breathing • auscultation • chest expansion • pulse oximetry [>95 hypoxic if <92 in air]

  20. Circulatory Failure CVS status • Heart rate • Pulse volume [peripheral and central] • Capillary refill peripheral and central] • Blood pressure HYPOTENSION late sign BP=80 +[age yrs x2]

  21. Age years <1 2-5 5-12 >12 Beats per min 110-160 95-140 80-120 60-100 Heart Rate

  22. Assessing capillary refill time • Capillary refill time > 2 seconds is abnormal

  23. Assessing skin perfusion • Skin colour • Pallor • Mottling • Cyanosis • Demarcation line

  24. Specific ABCDE assessments and interventionsC - Circulation

  25. Interventions • Intravenous access • Intraosseous access • Fluid 0.9% saline 10-20 ml/kg boluses

  26. Recognition of central neurological failure ABC Conscious level • A Alert • V responds to voice • P responds to pain • U unresponsive • Posture : decorticate decerebrate

  27. Specific ABCDE assessments and interventionsD - Disability

  28. Specific ABCDE assessments and interventionsE - Exposure

  29. Cardiorespiratory failure • There is always some respiratory compensation for circulatory failure and vice versa • In severe illness it may not be possible to determine whether the primary problem is respiratory or circulatory in origin

  30. Primary assessment Airway noises: patent at risk, obstructed Breathing: Noises,resp rate, saturations, recession, auscultation Circulation:Heart rate capillary refill time, pulses ,temperature demaracation Disability: AVPU, posture pupils & Don’t forget glucose Exposure: Temperature, rashes, bruises Resuscitation High flow oxygen IV or IO access ,bloods include glucose /bm. Consider fluid resuscitation 20 ml/kg 0.9% saline Consider A & B and check glucose/BM Point to diagnosis sepsis, NAI, meningococcal disease SUMMARY

  31. All children assessed acutely or undergoing procedures are observed using a Paediatric Early Warning System Chart Paediatric Early Warning System [PEWS charts]

  32. DoH intiative: SBAR[D] • Situation • Background • Assess • Response • Decision

  33. CASE • 3 year old short history of fever shaking & generally unwell • GP triage: high temp looks flushed no rash unwell child. Does ACBDE assessment [3 minutes] recognises seriously unwell. • Resp rate 36/min raised, sats 94% borderline, heart rate 170 tachycardic, CRT 2-3s responds just to voice. Rings ambulance says Sepsis 6 severe sepsis urgent response and rings A+E severe sepsis sepsis 6 attending.[thorough assessment but rapid, recognises seriously unwell, communicates well uses Sepsis 6 which ambulance crew & A+E know how to respond] • Ambulance crew start Sepsis 6 give high flow oxygen [start Sepsis6 response] • A+E Nurse & Dr Review [Probably severe /Sepsis 6]to resus area. ABCDE assessment responds with SEPSIS 6. [ A+E busy but prioritises this case and aware of SEPSIS6 so prepares for urgent response in resus area ,STRS drug calculator ]. • Child responds to treatment

  34. PAEDIATRIC SEPSIS 6 EKHUFT SEPSIS COLLABORATIVE INITIATIVE

  35. Sepsis Paediatric Cards

  36. Documentation Sepsis 6

  37. Leaflets : signposting

  38. Training Induction all paediatric doctors & ANPs : introduction to guidelines and sepsis scenario simulation training Simulation including sepsis regularly in clinical areas A+E doctors training in paediatrics with regular sessions covering sepsis Spotting the sick child website all encouraged to view and complete test. PEWS chart training and audit

  39. Initiatives in East Kent: Paediatrics Feverish Child Guideline 2015 Severe Sepsis in Children Guideline 2015 Paediatric Antimicrobial Guideline 2015 Sepsis Cards : to all departments seeing children Leaflets for feverish child 2015 Screening for Sepsis mandatory for all children with fever or PEWS score above 3.

  40. USEFUL RESOURCES • Paediatricians/Resuscitation officers • PiLS course • EPLS/ APLS course • NICE guidelines SEPSIS /FEBRILE CHILD <5 years • Sepsis 6 • Paediatric Advanced Life Support Manual • Medicines for Children Formulary • Spotting the sick child website /DVD www.spottingthesickchild.com

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