When is a child really sick?

When is a child really sick?

·        Factors which are not on their own discriminating between mild and severe: 

· Temperature: spikes easily

o   Pulse: variable, eg ­­ if crying 

o   Blood pressure: hard to measure, and if shocked is still maintained till very late. As soon as they have any hypotension they‟re the same as an adult with no recordable BP

·        Factors from history which discriminate:

o   Intake: 

§  Refusal to feed Þ more severe

§  Refusal to take solids but still taking liquids Þ not so bad

o   Losses:

§  Vomiting:

·        Frequency and amount: if vomiting their whole feed then bad (vs a small spill) 

·        Colour: Bile is bad. Yellow (from gallbladder), green (after bile has been in the stomach) or orange. Due to obstruction or ­­ sympathetic discharge, eg due to pain (not necessarily abdominal – could be a torted testicle) 

§  Decreased urine output (wet nappies < 4 per day)

§  Diarrhoeal losses

·        Dysuria and pale extremities may be the only warning signs before they crash

·        Factors which discriminate on exam: 

o   Floppiness: ¯tone

o   Perfusion: pale, mottled or blue, cold.  Capillary refill > 2 secs. (ie Peripheral vasoconstriction)

o   Fitting

o   Cyanosis

o   Tachycardia

o   Respiratory rate: quality as important as rate

o   Rash if petechial/purpuric (?meningococcal septicaemia) 

o   ¯pH

o   ¯Weight (dehydration)

·        Toxic Appearance =

o   Decreased level of arousal

o   Circulatory compromise: pallor, tachycardia, cool + mottled limbs, hypotension

o   Respiratory impairment:

§  Tachypnoea, grunting respirations, recession, cyanosis 

§  Due to ­ O2 requirements + trying to blow of CO2 from acidosis + pulmonary oedema from capillary leak 

·        Shock =

o   Clinical diagnosis of failure of the circulatory system to deliver sufficient O2 

o   Look for compensatory mechanisms which try to maintain perfusion of vital organs (­HR, peripheral vasoconstriction) 

o   Causes of shock: 

§  Capillary leak ® ¯ cardiac output

§  Changed vascular tone

§  Impaired myocardial function 

·        Progression: Toxic ® Septic ® Shock

·        Specific signs:

o   Meningism: bulging fontanel, rash, stiff neck

o   Pneumonia: chest sounds (not very sensitive)

o   Distended abdomen and guarding: obstruction, appendicitis 

o   Lumps in the inguinal region (seen or felt): hernia ® obstruction ® acidotic

o   Blood in faeces: Intussusception

·        Basic investigations:

o   Bloods: FBC, electrolytes, culture, ABG, (cross match)

o   X-rays: chest, abdomen if distended

o   Urine culture (bladder stab)

o   Maybe lumbar puncture

Neonates

·        Check list for a neonate (clinical acumen less reliable):

o   Fever: consider full sepsis evaluation for any child > 38 C

o   Feeding: if intake < 50% normal 

·        Urine output: < 4 wet nappies in 24 hours

·        Peripheral circulation: pallor of recent onset, mottling, cold periphery, slow capillary return

·        Responsiveness: poor response to stimulation and a weak cry 

·        Activity: ¯movement, ­sleepiness

·        Breathing difficulty: signs of distress, cyanosis, RR > 60 

·    Apnoea: pause in respiration > 20 secs.  Central (eg premature) or obstructive (eg URTI) or mixed

·        Vomiting: treat any vomiting in neonate seriously.  Look for bile staining

·        Cyanosis

·        Seizures

·        Severe jaundice: risk of bilirubin encephalopathy