Serious illness

Aim

To guide PCH Emergency Department (ED) staff with the assessment and management of serious illness.

Background 

• Many children present to the Emergency Department early in the course of a serious illness. Prompt recognition and targeted management to address early signs of respiratory, cardiac and neurological compromise in these children may prevent further progression of their illness.¹
• A child who presents with a life-threatening condition or collapse is an uncommon event.²
• Cardiorespiratory arrest in children is uncommon and is rarely due to primary cardiac disease.
• Cardiac arrest in children is most commonly due to hypoxia secondary to respiratory failure but may also be the result of circulatory failure or central neurological failure.
• A structured approach helps to identify and prioritise treatments for immediate threats to life.^1-4 The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a simple and highly effective method in resuscitation situations.^1,4
• An experienced team leader should allocate roles and delegate tasks while maintaining situational awareness.³
• Early requests for additional support should occur upon the recognition of a child with a serious illness.

Assessment

• A structured, systematic approach is essential when assessing seriously ill children.
• The initial primary survey with concurrent resuscitation follows the ABCDE approach. A secondary survey is then completed using the same structured approach to assess the response to initial treatment and to identify symptoms which require emergency treatment to stabilise the patient.¹

History

• A targeted history should aim to identify the underlying cause of the serious illness. A team member may be allocated to take a history while concurrent primary assessment and resuscitation are occurring. This history should focus on preceding respiratory, circulatory and neurological symptoms.

• The use of the structured approach will help to identify deteriorating patients with the aim of providing intervention early to prevent respiratory and cardiac failure resulting in cardiac or respiratory arrest.¹

  Respiratory Failure	Circulatory Failure	Central Neurological Failure
  Asthma Bronchiolitis Aspiration Pneumonia Foreign body Croup Poisoning	Anaphylaxis Septic shock Hypovolaemia Congenital Heart Disease Arrythmia Trauma	Raised intracranial pressure Infections Trauma Seizures

Recognition of the deteriorating child

• Children may deteriorate whilst in the Emergency Department.² Repeated assessment of patients will allow changes to be detected and may be requested by family members or staff caring for the child.
• The 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 located on the Observation and Response Tool. Consider using a MET call or Code Blue if indicated.
• Early recognition and treatment of impending respiratory, circulatory or central neurological failure may prevent cardiac arrest in children.²
• Using an Observation and Response Tool and the Early Warning Escalation Pathway assists with early detection of seriously ill children.
  • PCH uses the Paediatric Acute Recognition and Response Observation Tool (PARROT) chart and the PARROT Clinical Comments Chart. Refer to Observation, Monitoring and Paediatric Acute Recognition and Response Observation Tool (PARROT) - Clinical Practice Manual – (internal WA Health only).

Resuscitation and Primary Assessment

• Children with serious illness should be managed in appropriate area with consideration of moving them to a resuscitation bay.
• Senior medical staff should be notified if there is concern about a serious illness.
• Resuscitation and Primary Assessment occur concurrently with treatment of problems as they are identified. The aim is to detect immediate life-threatening problems and to intervene as they are found.^1,3
• Hypoxia and shock can cause a decrease in conscious level. Airway, Breathing and Circulation should be optimised before concluding decreased level of consciousness is a primary neurological problem.
• The ABCDE approach is used¹

Secondary assessment

The secondary assessment aims to establish the underlying cause of the serious illness and to stabilise the child. 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 objectives¹:

• Obtain a targeted history: Signs and Symptoms, Allergies, Medications, Past Medical History, Last meal, Events leading to this presentation.
• Detailed physical examination.
• Perform laboratory investigations and imaging to assist with diagnosis and to monitor progress.
• Establish a working diagnosis, with consideration of other possible differential diagnoses, and targeted therapy.
• Early antibiotics for suspected sepsis. Refer to Sepsis Recognition and Management – ED Guideline.

Ongoing assessment

Always reassess the patient to assess the effectiveness of emergency interventions provided and identify any other injuries or conditions. This should be performed after the secondary assessment, after completion of critical interventions or if there is a change in the patient's condition.

Once stabilised, patients should have the following monitored:

• ECG monitoring
• Pulse rate
• Respiratory rate
• Oxygen saturations
• Blood pressure
• Temperature

Depending on the working diagnosis the following monitoring may be indicated:

• Endotracheal tube carbon dioxide (ETCO₂)
• Venous blood gas
• Urine output (+/- urinary catheterisation)
• Invasive blood pressure (BP) monitoring (arterial line)
• Central venous pressure (CVP) monitoring
• Intracranial pressure (ICP) monitoring

Communication

• During the assessment and treatment of a critically unwell child a support person should be allocated to communicate with the family to obtain information and explain processes. This may be staff with specific health care training, such as medical or nursing staff, or may be a staff member with skills in pastoral care such as a chaplain or social worker.

References 

1. Advanced Paediatric Life Support: The Practical Approach. 6th ed Australia and New Zealand Version. Wiley & Sons Inc., 2017.
2. Textbook of Paediatric Emergency Medicine. 3rd Edition. Cameron P, Brown G, Biswadev M, et al. Elsevier, 2019.
3. Fleisher And Ludwig’s Textbook of Pediatric Emergency Medicine. 7th ed. Bachur RG, Shaw KN. Philadelphia: Wolters Kluwer, 2016.
4. Nelson Textbook of Pediatrics: 21^st Edition Kliegman RM, St. Geme J, Blum NJ, Shah SS et al. Publisher: Elsevier, 2020.

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