ABCDE management of an unwell child [advanced]

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A to E assessment

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 year	1-2 years	2-5 years	5-12 years	>12 years
Resp rate	30-40	25-35	25-30	20-25	15-20
Heart rate	110-160	100-150	95-140	80-120	60-100

Amber and red flags

	Amber flags	Red flags
A		Stridor
B	Nasal flaring, tachypnoea, sats <95%	Respiratory distress (RR>60)
C	Pallor, tachycardia, reduced capillary refill, reduced UO, dry mucus membranes	Pale/mottled/blue, reduced skin turgor
D	Reduced activity, not responding normally to social cues	Unresponsive/won’t stay awake, non-blanching rash/neck stiffness, seizures
E	Rigors, fever in 3-6month old	Fever in <3month old

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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.

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.

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.