ASSESSING SEVERITY OF ILLNESS IN THE CHILD

see Normal Paediatric Vital Signs

INTRODUCTION

• Applies particularly to neonates/infants/toddlers
• Don’t be intimidated
• Follow a systematic approach
• Assess severity first - diagnosis comes later

OVERVIEW OF PROCESS

• Initial assessment
• Occurs without needing to touch the child
• Can be performed rapidly in less than 1 minute
• Done at triage
• Taking of vital signs

COMPONENTS

• Airway
• Breathing
• Circulation
• Disability (Neurological)
• Exposure

• LIFE-THREATENING ILLNESSES ACT BY EXERTING THEIR EFFECT ON THE ABOVE

SERIOUS SIGNS

AIRWAY

• Stridor
• Tracheal tug
• Drooling

BREATHING

• Increased work
  • Recession
  • RR
  • Grunting
  • Nasal flare
  • Accessory muscle
• Increasing fatigue
  • RR
  • breath sounds
  • chest/abdominal movement
  • Apnoeic spells (c.f. periodic breathing)
• Decreasing effectiveness
  • Cyanosis
  • Alertness

CIRCULATION

• Pallor/Peripheral cyanosis
• capillary refill

DISABILITY

• Conscious state
  • Lethargic/Dull/Expressionless
  • Irritable
  • Not recognizing mother
  • Seizures
  • Not responding to pain
  • Quiet/Unresponsive
• Eye contact/Smile
  • Lack of social smile
  • Not Fixing/Following/Focusing
  • Glassy stare
• Activity
  • Require assistance
  • Not ambulating
• Cry
  • Unable to be placated by mother
  • Whimpering/Sobbing
  • Irritable
  • Weak/Moaning/High pitched

EXPOSURE

• Mottled
• Petechiae
• Unexplained bruising (NAI)

VITAL SIGNS

see Normal Paediatric Vital Signs

• Different reference range for different ages
• BP is an important value often forgotten
• Hypothermia is suggestive of sepsis
• Pulse oximetry - ‘the fifth vital sign’
• Weigh the child
• Check blood sugar

WHY WEIGH THE CHILD?

• Changes of weight are a good guide to degree of dehydration
• Determines drug dosing
• Determines IV fluid calculations

SIGNS OF SEVERE ILLNESS

• Resting stridor
• Marked intercostal/sternal recession with accessory muscle use and tachypnea
• Cyanosis
• Capillary refill > 4sec (normal < 2 sec) 
• Impalpable pulse or hypotension
• Not fixing/following or responding to environment

PRACTICAL TIPS

• Maintain a calm and reassuring manner (helps the parents and yourself)
• Keep a handy reference at triage of age-related ranges of paediatric vital signs
• When assessing capillary refill - choose an area of the trunk and apply pressure for 4 secs before releasing

• Assess pulse at brachial artery (inside elbow)
• Use age appropriate BP cuff (width 2/3 circumference)
• Use paediatric probe for pulse oximetry

• Weighing the child
  • use proper paediatric scales (NOT adult scales)
  • ideally unclothed with small babies
  • Record to within 0.1kg for a neonate
  • Record to 0.5kg for an infant