Spotting sick child

Spotting the sick child.

1. Spotting The Sick Child
DR AUNG KHIN THEIN
MBBS, M.Med.Sc(Paed), MRCPCH(UK)
LECTURER/ CONSULTANT PAEDIATRICIAN
YANKIN CHILDREN HOSPITAL
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AK Thein: Spotting The Sick Child. MMA, YGN

2. Outline

•Why it is important
•How we can spot the sick child
PAT
Stratification -Focus history
The 3 minute tool kit
•Case Scenario
•Summary

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3. Working in Busy PAU or A&E or GP Clinic: GRAY ZONE
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Well Sick

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5. Outline

•Why it is important
•How we can spot the sick child
PAT
Stratification -Focus history
The 3 minute tool kit
•Case Scenario
•Summary

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6. Pediatric Assessment Triangle (PAT)
• AAP introduced Pediatric Assessment Triangle (PAT) in 2000
• Is not a diagnostic tool
• The first general impression of the child
• Establish the severity of the presentation and category of pathophysiology
• Determine the type and urgency of intervention
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7. Benefits Of Pediatric Assessment Triangle

•Rapid assessment done in 30-60 seconds
•No tools needed
•Non-threatening to children
•Non-invasive
•Simple to do

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8. Pediatric Assessment Triangle (PAT)
Appearance
Work Of Breathing
Circulation
Reflects the adequacy of ventilation, oxygenation, brain perfusion, body
homeostasis, and central nervous system function
What you: See
Hear
Feel
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9. Appearance
•‘‘TICLS’’ mnemonic:
•T- Tone
•I- Interactiveness
•C- Consolability
•L- Look or Gaze
•S- Speech or Cry
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10. Work Of Breathing

•Audible abnormal airway sounds:
Stridor
 Grunting
 Wheezing
•Signs of increased breathing effort :
Abnormal positioning
 Retractions
 Nasal flaring

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11. Circulation to the skin
•Skin color and skin perfusion:
Pallor
Cyanosis
Mottling
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12. PAT: Respiratory Distress
Appearance
Work Of Breathing
Circulation to skin
Normal
Normal
Increased
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13. PAT: Respiratory Failure
Appearance
Work Of Breathing
Circulation to skin
Normal or abnormal
Abnormal
Increased or
decreased
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14. PAT: Shock
Appearance
Work Of Breathing
Circulation to skin
Abnormal
Abnormal
Normal
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15. PAT: (CNS) Dysfunction
Appearance
Work Of Breathing
Circulation to skin
Normal
Abnormal
Normal
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16. PAT: Cardiopulmonary failure
Appearance
Work Of Breathing
Circulation to skin
Abnormal
Abnormal
Abnormal
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17. PAT
Appearance Work of Breathing Circulation to skin General impression
Abnormal Normal Normal CNS dysfunction
Normal Abnormal Normal RD
Abnormal Abnormal Normal Respiratory Failure
Normal Normal Abnormal Compensated shock
Abnormal Normal Abnormal Decompensated shock
Abnormal Abnormal Abnormal Cardiopulmonary failure
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18. Outline

•Why it is important
•How we can spot the sick child
PAT
Stratification -Focus history
The 3 minute tool kit
•Case Scenario
•Summary

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19. Stratification: Focus History
•Age - < 3 months , 3-6 months , < 2 years
•Ex-Prem
•Syndromic conditions
•Oncological Patients
•Cardiac Problems
•Long term steroids
•DM
•All other chronic conditions

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20. Stratification: Focus History

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General Danger signs
General Danger signs

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22. Outline

•Why it is important
•How we can spot the sick child
PAT
Stratification -Focus history
The 3 minute tool kit
•Case Scenario
•Summary

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23. The 3 minute tool kit: ABCDE-ENT-TT
•A – Airway – Is it obstructed? E.g. secretions, foreign body, stridor
•B – Breathing – Recession, RR, SPO2, Auscultation
•C – Circulation – Color, HR, CRT, Temperature of hands and feet
•D – Disability – Pupils, limb tone & movement, AVPU/ GCS



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24. •E – Exposure – Examined top- to-toe?
AF- Full or depressed
Rashes – blanching or non- blanching
rash
Any evidence of injury/trauma
Bruises – Always think Non-accidental
injury in the non- mobile child
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25. •ENT – Ears, Nose and Throat
• T – Temperature
• T – Tummy
•D E F G – Don’t Ever Forget Glucose!
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26. Common
Dialect
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Common
Dialect

28. Outline

•Why it is important
•How we can spot the sick child
PAT
Stratification -Focus history
The 3 minute tool kit
•Case Scenario
•Summary

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29. Case1
•30 day old baby girl presented to A&E with a three day history of fever
and poor feeding
•Seen by Doctor A
•Sleeping , T 101 F, HR 180 min
•Chest – VBS only
•Heart- NAD
•Abdomen - NAD
•Plan- CP,CRP, Blood culture , Urine RE



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30. •3 hours after admission
•Lab called on- call MO
•CRP of 210
•WBC of 32
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31. Doctor B reviewed the child
Appearance Work Of Breathing
Circulation to skin
Normal
Abnormal
Normal
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Very drowsy
AK Thein: Spotting The Sick Child. MMA, YGN

32. The 3 minute tool kit: ABCDE-ENT-TT
•A – Patent and no noisy breathing
•B – Normally
•C – CRT < 2 sec, HR 180
•D – AVPU - U
•E – Exposure – Examined top- to-toe?
AF- Full and tense
Rashes – Nil
Any evidence of injury/trauma- Nil
Bruises – Nil


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33. •ENT – NOT DONE
• T – 99 F
• T – NAD
•D E F G – Don’t Ever Forget Glucose- 108 Mg%

•30 days old baby
•High Fever
•Poor feeding
•Abnormal Appearance
•Full- AF


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Stratification

PAT
3 minute tool kit
AK Thein: Spotting The Sick Child. MMA, YGN
NICE Red Flag

34. •ENT – NOT DONE
• T – 99 F
• T – NAD
•D E F G – Don’t Ever Forget Glucose- 108 Mg%

•30 days old baby
•High Fever
•Poor feeding
•Abnormal Appearance
•Full- AF


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Stratification

PAT
3 minute tool kit
AK Thein: Spotting The Sick Child. MMA, YGN
NICE Red Flag

35. Case 2
• One year old boy attended an out of hours GP clinic around 20:00 with
•D1 Fever and was off food
• T – 100F , BP 90/60 mmhg HR ??, CRT ??
•GC- Sleeping
•CVS- I+II
•Chest- VBS only
•Abdomen- NAD
•Dx- AVI
•Plan: PARACETAMOL and send back home
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36. •Parents were not happy with the doctor’s decision
•Brought their child to A&E of Children Hospital
•Arrived Hospital around 20:30

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37. Reviewed the child
Appearance Work Of Breathing
Circulation to skin
Mottled
Abnormal
Normal
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Drowsy
AK Thein: Spotting The Sick Child. MMA, YGN

38. The 3 minute tool kit: ABCDE-ENT-TT
•A – Patent and no noisy breathing
•B – Normally
•C – CRT 4 sec, HR 182
•D – AVPU - V
•E – Exposure – Examined top-to-toe?
AF- Normal
Rashes – Non- blanching rashes covering both legs
Any evidence of injury/trauma- Nil
Bruises – Nil


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39. •ENT – Not done
• T – 102 F
• Tummy – NAD
•D E F G – Don’t Ever Forget Glucose- 160 Mg%

•Poor feeding
•Abnormal Appearance
•HR 182
•CRT 4 sec
•Non-Blanching rashes



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PAT

3 minute tool kit

AK Thein: Spotting The Sick Child. MMA, YGN
NICE Red Flag
Stratification

40. •ENT – Not done
• T – 102 F
• Tummy – NAD
•D E F G – Don’t Ever Forget Glucose- 160 Mg%

•Poor feeding
•Abnormal Appearance
•HR 182
•CRT 4 sec
•Non-Blanching rashes



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PAT

3 minute tool kit

AK Thein: Spotting The Sick Child. MMA, YGN
NICE Red Flag
Stratification

41. Outline

•Why it is important
•How we can spot the sick child
PAT
Stratification -Focus history
The 3 minute tool kit
•Case Scenario
•Summary

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42. Summary
•Physiological derangement can endanger life rapidly
•Life can only be saved by treating or preventing physiological derangement
urgently which offer time for curative treatment to work
•Stratification is vital
•PAT is a useful tool to access physiological status of a child at a glance
•The three minute tool-kit is a quick top to toe assessment tool to :
 Pick up common physical signs
 Make a rapid physiological check

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43. References
•Adriana Yock. Assessment of the unwell child. Australian Family Physician Vol. 39, No. 5,
May 2010.
•Ana Fernandez, Javier Benito, Santiago Mintegi. Is this child sick? Usefulness of the
Pediatric Assessment Triangle in emergency settings. J Pediatr . 2017;93(s1):60- 67
•NICE. Traffic light system for identifying risk of serious illness.
https://guidance.nice.org.uk/CG160
• Spotting the sick child – e-learning l RCPCH
•https://www.rcpch.ac.uk/resources/spotting-sick-child-elearning


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44. Thank You
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