Airway Assessment

AIRWAY ASSESSMENT Patent or obstructed Chest rising or not Stridor or secretions Children have small airways -> can easily become blocked Importance to notice sounds of airway blockage E.g. secretions or stridor Each sound differently Foreign body Assessment depends on how critically ill the child Unprotected airway If child is under the care of an anaesthetists is the gag reflex Insert an oropharyngeal airway and seeing if there is a reaction If a child coughs -> they are protecting their airways If has an artificial airway or have an unprotected airway Maintain a jaw thrust Call an anaesthetist or call ambulance if not in hospital with an anaesthetist Breathing Component Description A measure of respiratory distress or more systemic problems E.g. septicaemia or diabetic ketoacidosis To measure accurately Resp Rate Count each breath over the 60 second period Best done when child is calm as crying or coughing can alter the rate considerably Normal range varies with age Recession and Accessory Mild, moderate and severe recession Muscle Use Pulse oximeter Doctors base many of their decisions based on oxygen levels Useful for two reasons: Children may appear happy even when saturation is low, and can be closer to decompensation to what one may think Eyes wont pick up cyanosis, until the condition is very serious SpO2 of 85% or less -> when cyanosis manifests Thus, gives early warning signs, that oxygenation is not where it should be Place probe on the finger so that the red-light shines through the finger Choose an appropriately sized probe Children under 10 need a smaller probe Shaped like a flexible piece of plastic rather than a clip In babies’ fingers are too small Can use whole hand or the forefoot Oxygen Saturation Secure it with some tape If child moves their feet for example -> this may cause an artificially low reading Because there will be a low amplitude so detecting signals is made difficult If you see a high reading followed by a low reading The high reading is usually correct – as an artificially high reading is unlikely Normally children should have a saturation of at least 96% Levels of less than 94% -> significant illness Levels below 90% are alarming If the child is restless: Turn it into a game Or just hold the limp still Children find the red light on the probe If have not made a definitive diagnosis but everything in checklist is normal Unlikely to be missing anything serious Some children may cry during this If they do, try to catch the breath sounds while they breath in May settle with a dummy or a finger to suck If stethoscope is cold -> warm it How to auscultate May let them play with and turn it into a game C hest is quite small, noises, including upper airway noises, transmit all over the chest, so auscultation is of less value than in adults. Usually the info we get, is if there is a wheeze or not e.g. in asthma or wet crepitation’s such as in bronchiolitis or bronchial breathing. Circulation Component Description Make a mental note of the child’s colour If pale Ask parents what their normal colour is like How to If agree child is pale Look for mottled arms or legs In a few children this is normal, but if parent say this unusual -> sign of poor perfusion Do when child Is calm Crying increases HR Measure for 30 seconds and multiply by 2 In children under 6 months, radial (?) pulse is hard to measure Heart Rate Brachial pulse is better Above the elbow on the inside of the arm In hospital more accurate to obtain from a pulse oximeter if the child is still or from a cardiac monitor Normal ranges vary by age Shows if circulation is compromised Checks if the body has constricted their blood vessels in the arms and legs in order to preserve the more important central circulation E.g. bacterial sepsis of dehydration Very useful measure in children, as the blood pressure does not drop until the child is extremely unwell and tachycardia is not a 100% reliable sign Should press for few second and then how long it takes for the white area to fill with a pink colour In normal children should be less than 2 seconds CRT 3 to 4 seconds -> circulatory problem 5 seconds -> urgent resus needed depending on rest of exam May be measured centrally by pressing on the sternum of forehead May be measure peripherally by pressing on fingers, toes, hands or feet Peripheral capillary refill time will be impacted first by it is also impacted by things like ambient temperature Central CRT more liable in as has fewer false positive results CRT is a sign of decompensation As per peripheral vasoconstriction Take a note when assessing for CRT Temperature of Hands and Feet Compare with the trunk Cooler if there is vasoconstriction such as in sepsis or dehydration Difficult to measure as children can become distressed Do not measure unless seriously worried such if child is drowsy or very sick appearing this is because blood pressure is maintained until very late in the shock process This is because children have a goof peripheral vasoconstriction to maintain Blood Pressure Use right cuff size Should measure 2/3 rd of the length of the arm If struggling to obtain, may be easier to obtain from thigh Disability Component Description Almost always normal in a child who is awake and orientated Sluggish response may happen after a fit or a drug overdose Changing pupil size may be a sign of ongoing seizures even if there are no tonic clonic movements Asymmetry of pupils Implies a space occupying lesion in the brain Pupil E.g. extradural or subdural haemorrhage from head injury An abnormal gaze may happen after a seizure Pupil assessment to light should involve: Sluggish Changing sizes Asymmetrical Comparison of the tone and movements of the limbs is important if you are worried that there is a space occupying lessons in the brain or a tumor causing seizure Limb tone and movement If you pick up a difference between left and right that has not been noted before – likely to need a CT of the brain In acute illness, these signs are only likely if the patient is not alert and orientated AVPO Alert? Responding to voice or pain? Is the child unresponsive? AVPO score and GCS CGS True irritability Child cannot be consoled or calmed Think about meningitis, raised intracranial pressure An increased temperature may not reliably reflect if the child is truly drowsy ENT assessment Younger children get irritated Hence better to leave for the end Always examine the ears and throat in any child with fever Ear Examination Throat Examination Sit the child facing you Parent wraps one arm around the child’s arm and the other on their forehead Sit the child on their parent’s lap Use a tongue depressor between breaths if the Ensure a firm hold – either by a parent ot a staff member child resists to prevent injury from otoscope Diagnostic cautions: One arm restraints the child’s arm, and the other against Pink eardrums: often due to fever -> not the chest necessarily otitis media Rotate the child for the other ear Red and large tonsilitis Common in children and not always tonsilitis True tonsilitis includes exudate on the tonsils Temperature Assessment Avoid mercury thermometer in young children due to safety risks Tympanic membrane Ideal for most children Not suitable for babies with small ear canals Paper strip thermometers E.g. tempadots Placed in the axilla or the out Prone to falling out or being misread Axillary temperature is prepared in small babies as they have small ear canals Tummy Assessment Positioning: Ideally done with the child lying flat on a trolley. If the child is very upset, use the parent’s lap once they’re calm. Trust & Relaxation: Gaining the child’s trust and helping them relax is essential, especially when abdominal pathology is suspected. Technique: Start with gentle palpation. Ask where it hurts. Once relaxed, proceed to deeper palpation to assess for: Tenderness Peritonism Masses Liver & Spleen: Examined the same way as in adults. Clinical Example: A child with appendicitis shows reproducible tenderness even when distracted, indicating genuine pain Blood Glucose Assessment Method: Most commonly done using a drop of blood on a reagent strip (BM Stix), read by eye or a small machine. When to Test: Not usually needed if the child is alert and oriented. Procedure: Prick the finger or toe, apply blood to the strip. Hypoglycaemia (Low Blood Sugar): Can occur due to: Low calorie intake over 1–2 days Alcohol ingestion Severe sepsis Congenital metabolic disorders Symptoms improve quickly with treatment. Hyperglycaemia (High Blood Sugar): Seen in diabetic ketoacidosis (DKA). Clues include high respiratory rate. Often confirmed via blood gas machine using a venous sample. Normal Range: 3–5 mmol/L in children. Difficulty in Breathing Difficulty in breathing and coughing are among the most common Most of time caused by viruses Mostly gets better on it own and does not need any specific treatment Most severe respiratory illnesses happen in the first 3 years Commonest organisms: S. pneumoniae Haemophilus influenzae Pertussis Mycoplasma Influenza virus Common causes of respiratory distress: Asthma Bronchiolitis Pneumonia Croup