You are a junior doctor in the Emergency Department and have been called to resus for a paediatric code blue.

Ambulance staff handover:

Situation: A 6-month-old has presented to the Emergency Department exhibiting symptoms of vomiting, drowsiness, and abdominal pain.
Background: The infant has had a 24-hour history of abdominal pain. The parents have reported a ‘jelly-like stool.’
Assessment: The child’s consciousness level varies, showing responsiveness to voice and pain (AVPU = V/P).
Recommendation: Full A-E assessment


  • Your task is to conduct an acute assessment of this child using the A-E method
  • Please note that you are not expected to take a history
  • Be prepared to answer the examiner’s questions at the end

A 6 month old baby is present in the station.

He is called Jerry Salters.

He has had a 24-hour history of abdominal pain and a ‘jelly-like stool.’ He has also had vomiting and drowsiness.

Additional information for examiner:

This child is experiencing decompensated circulatory failure secondary to intussusception. His airway is compromised due to a decreasing level of consciousness. This is an acutely unwell child, who requires IV fluid replacement to restore circulating volume.

Category Question
Assessment Initial Assessment:
Is it safe to approach?
Apply appropriate stimulation: gently shake the patient while conducting look, listen, and feel assessments. The child groans in response to pain
Conduct look, listen, and feel: observe for rise and fall of the chest, listen for airway noises, and feel for breath against the cheek

Airway Airway Assessment:
Look in the mouth for secretions or vomitus
Listen for transmitted airway sounds (none heard in this case)

Breathing Breathing Assessment:
Respiratory rate: 30 per minute
Signs of respiratory distress: intercostal and subcostal recession
Oxygen saturation: 94% on high-flow oxygen, or 85% if no supplemental oxygen is given
Apply 15 litres of oxygen through a non-rebreathe mask

Circulation Circulation:
Blood pressure: 60/30 mmHg
Central capillary refill time (measured on sternum): 5 seconds
Heart rate: 160 BPM

Circulation Circulation treatment:
IV cannula: successfully inserted by helper
Blood samples taken for: Full Blood Count (FBC), Urea and Electrolytes (U&E), C-Reactive Protein (CRP), and Venous Blood Gas (VBG)
IV fluid bolus administered

Question What fluid bolus would you give?
Balanced crystalloid solution (such as Hartmann's, Plasmalyte, or 0.9% Normal Saline)
Dosage: 10ml/kg

Disability Disability:
Blood sugar level: 7
Temperature: 37
Pupils are equal and reactive to light

Everything else Everything else:
Full exposure
Palpate abdomen

Re-assessment Re-assessment:
Reassess the patient using the ABCDE approach
Specifically, check if the candidate reassesses the cardiovascular system after the fluid bolus is administered

Question What are the potential surgical causes of acute abdomen in infancy?
Malrotation or volvulus
Necrotising enterocolitis
Hirschsprung enterocolitis

Question Can you define Intussusception?
Intussusception is a condition where a part of the intestine (typically the small intestine) slides into an adjacent part, much like the pieces of a telescope.
Usually at the terminal ileum or ileocaecal valve

Question How is Intussusception commonly diagnosed - what would be the classical feature seen in this investigation?
Ultrasound is the diagnostic modality of choice

Question On ultrasound imaging what is the classic image finding of intussusception
"target sign" or "doughnut sign"

Question After your assessment, what would be your management of this child?
Involvement of paediatric registrar
Discussion with paediatric surgeons

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