What Causes Most Life-Threatening Emergencies?

Infants: infection, trauma (particularly child abuse), metabolic disorders, and congenital defects.

Toddlers and older children: trauma, either unintentional or inflicted.

Adolescents: trauma, especially when alcohol and automobiles mix.

As discussed in Chapter 11, preventable trauma must be addressed at all health supervision visits with attention to developmental risks, the potential for abuse, domestic violence, and high-risk situations. Specific emergency situations are discussed in Chapter 59.

How Do I Recognize Life-Threatening Emergencies?

Your first task is to determine whether the child is critically ill, which is perhaps the most important skill that you learn in the pediatric clerkship. Your goal should be to use history, physical examination, and diagnostic tests consistently and reproducibly to determine if a problem is potentially life-threatening.

How Do I Identify the Critically Ill Patient?

A critically ill patient has a process that interferes with the delivery of oxygen and nutrients to the end organs. History and observation help you assess oxygenation and perfusion of critical organs because even subtle signs of organ dysfunction can provide clues to a critical illness.

Which Patient Presentations Should Cause Concern?

Certain scenarios may reflect a potentially life-threatening condition, despite the child’s initial appearance, and almost always require additional diagnostic studies:

How Should I Structure the Physical Examination?

Use the primary survey for all patients. This initial physical examination is known as the ABCs but is often extended to include “D” and “E,” as described in the next section. The primary survey must be followed in an unvarying sequence to ensure that you will identify life-threatening illnesses or injuries. Only after the ABC(DE)s are completed do you perform a careful head-to-toe examination, the secondary survey.

What Are the ABC(DE)s and How Do I Perform Them?

The ABC(DE)s are performed in the following unvarying sequence:

Airway. Go to the head of the bed. Open the airway by extending the neck. For infants, this means placing a blanket under the shoulders to slightly extend the neck and tilt the head into a “sniffing” position. If you hyperextend the neck of an infant, the airway may collapse. For older children, the neck must be extended more to open the airway. You can also use a jaw thrust to move soft tissue structures and further open the airway. To do this, place your index fingers behind the posterior portion of the mandible and push forward. Administer 100% oxygen if needed. If any concern exists about cervical spine injury, use only the jaw thrust to open the airway and maintain cervical spine immobilization.

Breathing. Look at the chest wall to assess respiratory rate, adequacy of chest rise, and work of breathing. Generally, newborn infants have respiratory rates of about 50 breaths/min, but by 1 year, the respiratory rate declines to 30 breaths/min. Respiratory rate above 60 breaths/min may signal respiratory distress in an infant. Rates slowly decrease to adult levels after age 1 year. Listen to the chest bilaterally, preferably almost at the axilla to avoid confusion with sounds from the opposite lung. Obtain a pulse oximetry reading. If ventilation is inadequate, you may need to provide bag-valve-mask (BVM) support with 100% oxygen.

Circulation. To determine whether the patient is in shock, start by checking the pulses. Find the femoral or brachial pulse in an infant or young child (the carotid pulse is often difficult to find). Next, feel for a peripheral pulse (radial is usually best). Determine the heart rate, remembering that tachycardia is an early sign of shock. Newborn infants have heart rates up to 160 beats/min. By 1 year, the heart rate slows to 120 beats/min, then slows further as the child grows. Check capillary refill by pressing a finger tip or toe. Keep the extremity at or above the heart so you are not checking venous refill. Look for active bleeding and stop it if possible. Finally, obtain a blood pressure; if you are alone this can be deferred, but not left out.

Disability. This mini-neurologic assessment ascertains mental status and the risk for central nervous system herniation:

Check pupils for size and responsiveness to light. Abnormalities will help make an early diagnosis of brain stem herniation and poisonings.

Establish the level of alertness. Look at the eyes for response when the patient is stimulated. All but the youngest neonates should at least look back at you. The “AVPU” scale is often used:

A = Alert

V = Responds to verbal stimuli

P = Responds to pain only

U =Unresponsive

Exposure/Environment. Undress the patient so that you can complete a thorough physical examination. Then think about the environment and take measures to prevent hypothermia.

What Tools Can Help Me Identify a “Sick” Infant or Child?

A number of scales are used to quantify severity of illness in infants and young children, but they are mostly used as research tools. The Yale Observation Scale (Table 33-1) can help you learn to identify the “sick” or “toxic” appearing child.

What Diagnostic Tests Should I Order for the Initial Evaluation?

Order diagnostic tests only after the ABCs are completed and the patient has been stabilized.