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When assessing an ill or injured child, the goal is to quickly recognize conditions that may be life-threatening or may become life-threatening if not cared for right away. If a child is not breathing, or does not have a pulse, rescue breathing or CPR should be started right away. If a child has a pulse and is breathing, then critical signs to look for are respiratory distress, respiratory failure, and shock. These are the most common issues in a pediatric patient that can quickly lead to respiratory or cardiac arrest. Now the main idea is to constantly evaluate, identify and intervene until the child patient is stable. For example, A primary assessment is done to evaluate immediate life-threatening conditions. If an immediate life-threatening condition is identified, we would intervene with the proper treatment. If the primary assessment does not show immediate life-threatening conditions, a secondary assessment should be done with a focused medical history and a focused physical exam to evaluate conditions that may need to be addressed; after this, other evaluation tools may be needed to diagnose a child’s condition, such as labs, radiographic, and other advanced tests. Now, to begin evaluating an ill or injured child one should use a systematic approach in order to unify and stay consistent with that assessment process. First, form an initial impression. This is a quick observation, formed in the first few seconds of the child's interview and assessment. Appearance, breathing, and signs of circulation are all evaluated at this time. This will help us determine an initial need for care of life-threatening conditions and the urgency for treatment and transport. Perform a primary assessment. If when tapping and shouting to the patient, we find that the child is unresponsive, we'd call for help or activate the emergency response system. Next, we would check for a pulse and signs of breathing. If there isn't any breathing, but the child has a pulse, we would provide rescue breathing at 1 breath every 2-3 seconds. And if there is no pulse, we would begin full CPR. Remember, if a child’s heart rate is below 60 beats per minute with signs of poor perfusion, we begin chest compressions. Now, if there is no life-threatening emergency, we would continue forming our initial impression of the child by looking at three primary signs; overall appearance of the child, their effort for breathing, and their circulatory status. It’s important to try to keep the child as calm as possible. Let the child stay with a parent or a caregiver if it's practical to do so while we perform those initial assessments. Now we may need to use a toy to distract the child in order to keep them calm while performing the assessments, but be creative. Try to find a way to keep them at ease while we're doing this evaluation process. It's all a part of our professional know-how. Now to evaluate the overall appearance of the child: check the child’s level of consciousness and ability to interact. Now, one key note here: make sure we're looking for things that maybe only a caregiver would know. In other words, I could say: "Is this the normal level of reaction that this child does for you, under this certain circumstance?" And follow what the caregiver says to get a baseline understanding of what is normal for this child. We know that they're all over the board. Some are very calm, some are very excitable, some cry, some don't cry, so look for abnormal normalities. And when looking at the child’s eyes, is there a normal look or do you see a gaze or an unusual stare, almost like they're looking through you or they're not really in the program? Does the child appear to be in pain? Is the child acting normal? What is the child’s muscle tone? Is the body position normal for this child? Is the child’s verbal response or cry normal? For the next part of the initial impression look at the child’s breathing. We're going to determine whether a child has increased respiratory effort by assessing the patient's position, accessory muscle use, and sounds of breathing that can be heard without a stethoscope. Is the child in a tripoding position? This is when a child leans forward with the hands on the knees, trying to keep the pressure off the lungs, in order to breath deeply or adequately. Do we see retractions, nasal flaring or accessory muscle use? Do you hear stridor, unusually deep or shallow respirations, wheezing, or grunting or crackles? Remember that if we see these signs of respiratory distress, don’t delay treatment of that particular condition. This is an emergency. And respiratory distress can quickly lead to respiratory arrest in a child. Now the last part of the initial impression is to evaluate the child's overall circulatory status based on general color. Any severe bleeding would need to be controlled and we should ask ourselves questions like the following: Does the child have pale, mottled, or cyanotic looking skin? Now, if the child has a dark skin complexion, look on the inside of the lips for the mucous membrane or to the fingertips or nailbeds. These can help us when we have different pigmented discolorations or colorations, when we can't tell whether the person is cyanotic or if they're pink, warm and dry. Cyanosis of the lips and the fingernails are early signs and symptoms of a circulatory compromise or oxygenation compromise. And these symptoms can be a sign that the child has inadequate oxygen in the blood. A flushed appearance can suggest fever or shock. Bruising on the skin can suggest injury or internal bleeding. And the idea is to quickly assess how well the child is perfusing through this simple observation. So in review, a systematic approach includes forming an initial impression. We do this by visualizing the child’s overall appearance, the work and effort for breathing and the signs of the circulation by the appearance of the skin color. And using a primary assessment to determine life-threatening conditions with the ABCDE approach. As part of the primary assessment, establish baseline vital signs by measuring respirations, their blood pressure and a pulse oximetry. After the primary assessment is performed a secondary assessment to determine other conditions which may need treatment should then proceed. We want to continue to reevaluate, identify, and intervene as treatments are given or the child’s condition changes.
When assessing an ill or injured child, your goal is to recognize conditions quickly, especially if they're life threatening or could become life threatening if care and treatment are not provided as soon as possible.
In this lesson, we'll go over this systematic approach to assessing a child in these circumstances. And we'll provide tips and details for this approach. An approach that can best be summed up this way: Evaluate, identify, and intervene.
If you find that the child isn't breathing and doesn't have a pulse, begin full CPR and rescue breathing immediately. If the child has a pulse and is breathing, there are still some important signs to look for including:
These are the most common issues for pediatric patients that can quickly deteriorate into respiratory arrest and eventually cardiac arrest.
This is the big picture approach to helping an ill or injured child. It includes recognizing any life-threatening emergencies and intervening with the proper treatment.
However, if there aren't any immediate life-threatening issues, you'll move on to your initial and primary assessment that will focus on medical history and a physical exam to evaluate for any secondary conditions that may need to be addressed.
Evaluation tools you might want to use include lab tests, radiographic tests, and other advanced tests. But to begin your assessment, you'll use a systematic approach in order to be more consistent and to reduce the chances of missing something important.
The first thing you'll want to do is quickly observe the child for anything obvious. Evaluate their appearance, breathing, and circulation. Doing this should help you determine if there is an urgent need for care and to recognize any life-threatening issues.
When performing your primary assessment, and after your shouts and taps, if the child is still unresponsive, call for help immediately and activate EMS.
If the child isn't breathing, but has a pulse, begin rescue breathing – 1 breath every 3 seconds. If the child isn't breathing and has no pulse, begin full CPR.
Pro Tip #1: If the child's heart rate is below 60 beats per minute with signs of poor perfusion, go immediately into chest compressions and full CPR.
However, if you don't find any life-threatening conditions, continue to perform your initial assessment by looking at three distinct areas: overall appearance, effort when breathing, and circulatory status.
Pro Tip #2: It's important to keep the child as calm as possible. This will usually include having a parent or primary caregiver nearby that can help, if practical, while you continue to assess the patient. You may need to get creative and find ways to put the child at ease during your evaluation process.
While evaluating the overall appearance of a pediatric patient, there are a few things to look for:
Pro Tip #3: How do you know what normal looks like? If there's a parent or caregiver present, get their help, and ask them if their child is acting normally or differently. Otherwise, you'll have no way of knowing what this child's version of normal looks like.
Does the child appear to be having trouble breathing? Look first at their body position, then the amount of accessory muscle tone, and finally audible sounds of breathing that can be heard without a stethoscope.
Is the child in what we call a tripod position – leaning forward with their hands on their knees. This is usually done to keep pressure off the lungs and diaphragm, which makes labored or inadequate breathing a little more easily accomplished.
Do you see any signs of retractions, nasal flaring, or signs of accessory muscles being used to aid breathing?
Do you hear stridor or unusually deep or shallow respirations, wheezing, grunting, or crackles? If you see any of these signs of respiratory distress, don't delay. This is an emergency situation that can quickly lead to respiratory arrest in a child.
This is the last step of your initial assessment and one that you'll use the child's overall color to determine. Ask yourself, does the child have pale, mottled, or cyanotic looking skin?
If you notice a strange complexion that you suspect may be due to cyanosis, look at the mucous membrane on the inside of the child's lips, their fingertips, or their nailbeds.
Cyanosis of the lips and fingernails are early signs of circulatory compromise and oxygenation issues and symptoms that the child has inadequate oxygen in their blood.
If the child has a flushed appearance, this could indicate fever or shock. If the child has bruising on their skin, this could indicate an injury and/or internal bleeding. The idea of this systematic approach is to quickly assess how well the child is perfusing through your observation.
Pro Tip #4: Use the ABCDE method as part of your primary assessment: airway, breathing, circulation, disability, and exposure. After your primary assessment, perform a secondary assessment to determine other conditions that may require treatment. And always remember to continually evaluate, identify, and intervene, when necessary and as the child's condition changes.