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ABCDE management of an unwell child [advanced]

A to E assessment

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Note: Only move to the next letter when the one before has been treated, and keep re-assessing ABCDE from the start as necessary

Normal observations

NORMAL<1 year1-2 years2-5 years5-12 years>12 years
Resp rate30-4025-3525-3020-2515-20
Heart rate110-160100-15095-14080-12060-100

Amber and red flags

 Amber flagsRed flags
A Stridor
BNasal flaring, tachypnoea, sats <95%Respiratory distress (RR>60)
CPallor, tachycardia, reduced capillary refill, reduced UO, dry mucus membranesPale/mottled/blue, reduced skin turgor
DReduced activity, not responding normally to social cuesUnresponsive/won’t stay awake, non-blanching rash/neck stiffness, seizures
ERigors, fever in 3-6month oldFever in <3month old

Possible investigations

  • Review child’s history in medical notes to help determine what is required
  • Only do investigations that will change management
  • BOXES
    • Bloods: FBC, CRP, cultures, VBG, capillary blood gas (if low sats), glucose
    • Orifice tests: urine dip and culture (parents to wait with sterile pot; in and out catheter may be used in young children if waiting too long); stool culture (if diarrhoea)
    • X-rays/imaging: CXR (if respiratory signs)
    • ECG (if HR>200 – ?SVT)
    • Special tests: lumbar puncture (if <3months or very unwell or meningitis suspected)
  • Any condition specific treatments

Request help as required

  • Inform senior

Document in notes

  • Document with a brief case summary, ABCDE headings with findings and management
  • Review child and results as necessary

Test yourself with some scenarios

You review a 2 year old in the emergency department. Her parents have brought her due to noisy breathing. On examination you hear stridor and notice subcostal recession. Observations are taken: respiratory rate 40, saturations 92% air, HR 160, temperature 39.2.

What is the differential diagnosis for stridor?

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You suspect the child has croup. What are the other signs of croup?

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What is the likely cause of the infection?

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You start an A-E assessment and are concerned about the airway. What would you do to manage this?

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Later in you shift you are called to the emergency department resus area. You are asked to review a 2 month old boy who is drowsy. The nurse has taken some observations, which show respiratory rate 40, heart rate 180, saturations 91% air, temperature 39.9. He is only responsive to pain on the AVPU scale. On examination he has dry mucus membranes and won’t stay awake. You undress him and notice he is mottled with a non-blanching rash.

What are the causes for a non-blanching rash?

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Which red and amber flags have you noticed?

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What diagnosis are you most concerned about?

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Which interventions would you include in each part of your A-E assessment?

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You are called to see a 13 year old on the paediatric assessment unit, referred in by their GP for an undifferentiated febrile illness. She has just returned from a 3 week holiday back to Nigeria, where she was born. The nurse has already done the observations and they show: respiratory rate 20, heart rate 140, oxygen saturations 99% air, temperature 40.1. On examination she is drowsy (alert to voice only). She looks dehydrated with dry mucus membranes and reduced skin turgor. There are no other focal examination findings and the chest is clear and abdomen soft and non-tender.

Which are the main parts of the A-E assessment you are concerned about? How would you manage them?

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Glucose is checked and is 2.1mmol/L. How would you manage this?

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Which investigations would you request?

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The lab calls to say the malaria test has come back positive. It looks like P. falciparum with a parasitaemia of 4%. What additional treatment would you give?

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