Paediatric emergencies

There are few situations that provoke greater anxiety than being called to see a child who is seriously ill. This chapter outlines a basic approach to the emergency management of seriously ill children.

The seriously ill child

The rapid clinical assessment of the seriously ill child will identify if there is potential respiratory, circulatory or neurological failure. This should take less than 1 minute. Normal vital signs are shown in Figure 6.1 and how a rapid assessment is performed is shown in Figure 6.2.

Figure 6.1 Variation in the normal range for respiratory rate, heart rate and systolic blood pressure with age.

Resuscitation is given immediately, if necessary, followed by secondary assessment and other emergency treatment.

The seriously ill child may present with shock, respiratory distress, as a drowsy/unconscious or fitting child or with a surgical emergency. Their causes are listed in Figure 6.4. In children, the key to successful outcome is the early recognition and active management of conditions that are life-threatening and potentially reversible.

Figure 6.4 The main modes of presentation of serious illness in children and their causes.

Summary

Regarding the seriously ill child

• Prevention of cardiopulmonary arrest is by early recognition and treatment of respiratory distress, respiratory or circulatory failure.

Capillary refill time is affected by body exposure to a cold environment.

Cardiopulmonary resuscitation

In adults, cardiopulmonary arrest is often cardiac in origin, secondary to ischaemic heart disease. In contrast, children usually have healthy hearts but experience hypoxia from respiratory or neurological failure or shock. If this occurs, irrespective of the cause, basic life support must be started immediately.

Box 6.1 AVPU rapid assessment of level of consciousness – more detailed evaluation is with the Glasgow Coma Scale (see Table 6.2)

A score of P means that the child’s airway is at risk and will need to be maintained by a manoeuvre or adjunct.

Basic life support

See Figure 6.5.

Advanced life support (Fig. 6.6)

Children who have been resuscitated successfully should be transferred to a paediatric high-dependency or intensive care unit.

The seriously injured child

Management of the seriously injured child must take account of potential injury to the cervical spine and other bones and internal injuries (Fig. 6.7).

Shock

Shock is present when the circulation is inadequate to meet the demands of the tissues. Critically ill children are often in shock, usually because of hypovolaemia due to fluid loss or maldistribution of fluid, as occurs in sepsis or intestinal obstruction.

Why are children so susceptible to fluid loss?

Children normally require a much higher fluid intake per kilogram of body weight than adults (Table 6.1). This is because they have a higher surface area to volume ratio and a higher basal metabolic rate. Children may therefore become dehydrated if:

Table 6.1

Fluid intake at different ages

Body weight	Fluid requirement/24 h	Volume/kg per hour (approximate)
First 10 kg	100 ml/kg	4 ml/kg
Second 10 kg	50 ml/kg	2 ml/kg
Subsequent kg	20 ml/kg	1 ml/kg
Examples of calculations
Infant (7 kg)	700 ml	28 ml/h
Child (18 kg)	1000 + 400 = 1400 ml	40 + 16 = 56 ml/h
Adolescent (42 kg)	1000 + 500 + 440 = 1940 ml	40 + 20 + 22 = 82 ml/h

• they are unable to take oral fluids

• there are additional fluid losses due to fever, diarrhoea or increased insensible losses (e.g. due to increased sweating or tachypnoea)

• there is loss of the normal fluid-retaining mechanisms, e.g. burns, the permeable skin of premature infants, increased urinary losses or capillary leak.

Clinical features

The clinical features of shock are manifestations of compensatory physiological mechanisms to maintain the circulation and the direct effects of poor perfusion of tissues and organs (Box 6.2).

Box 6.2 Clinical signs of shock

Early (compensated)	Late (decompensated)
Tachypnoea Tachycardia Decreased skin turgor Sunken eyes and fontanelle Delayed capillary refill (>2 s) Mottled, pale, cold skin Core–peripheral temperature gap (>4°C) Decreased urinary output	Acidotic (Kussmaul) breathing Bradycardia Confusion/depressed cerebral state Blue peripheries Absent urine output Hypotension

In early, compensated shock, the blood pressure is maintained by increased heart and respiratory rate, redistribution of blood from venous reserve volume and diversion of blood flow from non-essential tissues such as the skin in the peripheries, which become cold, to the vital organs like brain and heart. In shock due to dehydration, there is usually >10% loss of body weight (see Ch. 13) and a profound metabolic acidosis which is compounded by failure to feed and drink while severely ill. After acute blood loss or redistribution of blood volume because of infection, low blood pressure is a late feature. It signifies that compensatory responses are failing.

In late or uncompensated shock, compensatory mechanisms fail, blood pressure falls and lactic acidosis increases. It is important to recognise early compensated shock, as this is reversible, in contrast to uncompensated shock, which may be irreversible.

Management priorities

Fluid resuscitation

Rapid restoration of the intravascular circulating volume is the priority (Fig. 6.8). This will usually be with 0.9% saline, or blood if following trauma.

Subsequent management

If there is no improvement following fluid resuscitation or there is progression of shock and respiratory failure, a paediatric intensive care unit should be involved and transfer arranged as the child may need:

• tracheal intubation and mechanical ventilation

• invasive monitoring of blood pressure

• inotropic support

• correction of haematological, biochemical and metabolic derangements

• support for renal or liver failure.

Septicaemia

Bacteria may cause a focal infection or proliferate in the bloodstream, leading to septicaemia. In septicaemia, the host response includes the release of inflammatory cytokines and activation of endothelial cells, which may lead to septic shock. The commonest cause of septic shock in childhood is meningococcal infection, which may or may not be accompanied by meningitis. Fortunately, its incidence in the UK has fallen markedly since immunisation was introduced against meningococcal C, but other strains are still prevalent. Pneumococcus is the commonest organism causing bacteraemia, but it is unusual for it to cause septic shock. In neonates, the commonest causes of septicaemia are group B streptococcus or Gram-negative organisms acquired from the birth canal.

Clinical features

See Box 6.3

Box 6.3 Clinical features of septicaemia

History	Examination
Fever Poor feeding Miserable, irritable, lethargy History of focal infection, e.g. meningitis, osteomyelitis, gastroenteritis, cellulitis Predisposing conditions, e.g. sickle cell disease, immunodeficiency	Fever Tachycardia, tachypnoea, low blood pressure Purpuric rash (meningococcal septicaemia) (Fig. 6.9). Shock Multi-organ failure