Serious illness

Aim

To guide PCH ED staff with the assessment and management of serious illness.

Background

General

• A child who presents with a life threatening condition or collapse is a relatively uncommon event but often causes anxiety and presents a major challenge to clinicians
• A structured approach will enable a clinician to manage these emergencies
• This structured approach initially focuses on identifying and treating immediate threats to life
• Following this initial primary survey and resuscitation, the structured approach is again used as a secondary survey to identify other key symptoms and signs which require emergency treatment to stabilise the patient
• Most children, however, will not present with a life threatening condition but may show signs and symptoms of serious illness
• The use of the structured approach will identify a deteriorating condition potentially avoiding pre-arrest and arrest situations
• There should be an experienced team leader who allocates roles and delegates tasks while maintaining situational awareness.

Assessment

• A structured, systematic approach is essential when assessing seriously ill children.
• Early recognition and treatment of seriously ill patients may prevent deterioration and potential arrest situations.
• Primary survey using the 'ABCDE' approach is a simple and highly effective method in resuscitation situations.

History

• Cardiorespiratory arrest in children is rarely due to primary cardiac disease.
• In children, it is most commonly due to hypoxia and respiratory failure (secondary to foreign body, bronchiolitis, asthma, pneumonia, aspiration). Circulatory failure (due to septic shock, anaphylaxis, severe dehydration, congenital heart disease) and central neurological failure (raised intracranial pressure, meningitis, seizures) may also lead to cardiorespiratory arrest.
• Therefore, recognition of impending respiratory failure, circulatory failure or central neurological failure is paramount in preventing arrest situations in children.
• This is the basis of paediatric early warning scores which have been introduced in various hospitals, including PCH (Paediatric Acute Recognition and Response Observation Tool (PARROT) chart and the PARROT Clinical Comments Chart (internal WA Health only)).

Recognition of the deteriorating child

• A structured approach should identify a deteriorating child and any impending respiratory, cardiovascular or central neurological failure.
• Concern for a seriously ill child or deteriorating child should prompt early senior ED doctor or Paediatric Critical Care review as outlined in the Early Warning Score Escalation Pathway. Consider MET call or Code Blue if indicated.

Management

Secondary assessment

The primary survey is an initial assessment aimed at detecting immediate life threatening problems that can compromise basic life functions. The secondary assessment focuses on ongoing reassessment and management. It is important to perform an additional assessment with a focused history and physical examination in stable patients. The secondary survey is intended to detect less immediate threats to life and has several specific objectives:

• Obtaining a complete history, including mechanism of injury or circumstances of the illness
• Performing a detailed physical examination
• Establishing a clinical diagnosis and targeted therapy
• Early antibiotics for suspected sepsis. See Sepsis recognition and management guideline.
• Performing appropriate laboratory investigations and imaging.

Ongoing assessment

Always reassess the patient. The purpose is to assess the effectiveness of the emergency interventions provided and identify any missed injuries or conditions. This should be performed in every patient after the detailed physical examination and after ensuring completion of critical interventions.

Once stabilised, patients should have the following monitored:

• ECG monitoring
• pulse rate
• respiratory rate
• oxygen saturations
• blood pressure
• temperature.

Consider monitoring of:

• endotracheal tube CO₂
• venous blood gas
• urine output (+/- urinary catheterisation)
• invasive BP monitoring (arterial line)
• CVP monitoring
• ICP monitoring.

Bibliography

1. Advanced Paediatric Life Support: The Practical Approach. 5th ed Australia and New Zealand Version. Wiley-Blackwell, 2011.
2. Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S. Philadelphia: Lippincott Williams & Wilkins, 2010.
3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier
4. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012

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