RECOGNITION

OF
CRITICALLY ILL CHILD
YOGI PRAWIRA

INDONESIAN PEDIATRIC SOCIETY < 1 >

 Goals
•  Know the sequences in recognizing critically ill
child

•  Paediatric Assessment Triangle: a quick look

•  ABCDE

•  Classification and management priority

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 Sequences in recognizing
A critically ill child

01 02 03 04 05

Quick Primary Secondary Tertiary
Re-assessment
look assessment assessment assessment

PAT ABCDE •  History taking Diagnosis

•  Focused
physical exam
•  Detailed exam
INDONESIAN PEDIATRIC SOCIETY < 3 >
Paediatric Assessment Triangle: a quick look

Body Colour

C
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Paediatric Assessment Triangle: a quick look

•  Tonus

•  Interactiveness

•  Consolabillity

•  Look/gaze

•  Speech/cry

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INDONESIAN PEDIATRIC SOCIETY < 6 >
INDONESIAN PEDIATRIC SOCIETY < 7 >
Paediatric Assessment Triangle: a quick look

•  Abnormal breathing sounds

•  Abnormal position

•  Retraction

•  Flaring of the nares

•  Abnormal breathing patterns

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Work of Breathing Assessment

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INDONESIAN PEDIATRIC SOCIETY < 10 >
INDONESIAN PEDIATRIC SOCIETY < 11 >
Paediatric Assessment Triangle: a quick look

•  Pallor
•  Mottling
•  Cyanosis
Body Colour

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Mottling

Cyanosis
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Respiratory Distress

N ↑

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 Shock

≠N N

≠N

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Primary CNS/Metabolic Problem

≠N N

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Cardiorespiratory Failure

≠N ↑/↓

≠N

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❑  First Observational Assesment (PAT) à BBB
❑  Primary Assessment à ABCDE

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 A

•  Patent
•  At Risk
•  Obstructed

Infant < 6 mo à
preferential nose breather

INDONESIAN PEDIATRIC SOCIETY < 19 >

 Abnormal Sounds Indicative of
Extrathoracic Airway Obstruction

Mechanism Examples
Hoarseness Unilateral vocal cord paralysis

Muffled voice Supraglottic or infraglottic
processes, including epiglottitis
“Hot potato” voice Oral, retropharyngeal abscess
Cellulitis or connective tissue
infection of the floor of the mouth
also known as Ludwig’s angina
“Barking” cough Laryngotracheobronchitis (croup)

Monotone, hurried sentence Bilateral vocal cord paresis

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 B
•  Respiratory Rate
•  Work of Breathing
•  Tidal Volume
•  Oxygenation

INDONESIAN PEDIATRIC SOCIETY < 21 >

Diaphragm
•  Circular attachment to the
thoracic wall, works like a piston
to enlarge thorax and displace
abdominal contents downward
à main respiratory muscles
•  Mechanical obstruction:
•  Abdominal origin (gastric
distention,
pneumoperitoneum,
intestinal occlusion)
•  Pulmonary origin
(hyperinflation, FBA)

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 C
5P

1. Pulse – Heart Rate

2. Peripheral Perfusion

3. Pulses Volume

4. Blood Pressure

5. Preload

INDONESIAN PEDIATRIC SOCIETY < 23 >

 C

INDONESIAN PEDIATRIC SOCIETY < 24 >

 Mean Arterial Pressure

MAP (mmHg)

Normal 55 + (1.5 x age in years)

Minimum 40 + (1.5 x age in years)

INDONESIAN PEDIATRIC SOCIETY < 25 >

 •  Level of Consciousness →
D
AVPU
•  Brain stem function
•  Motor
-  Seizure
-  Assymetrical movement
-  Posture
-  Flaccid/Spastic

INDONESIAN PEDIATRIC SOCIETY < 26 >

Altered Mental Status

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Pupillary Light Reflex

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Breathing Pattern

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 Brain stem disorders

CNS Level Pupil Doll’s eyes Breathing Posture

Small, Cheyne-
Thalamus Variable Normal
reactive Stokes

Mid position, Hyper-

Midbrain Absent Decorticate
fixed ventilation

Pin-point, Rythmic Decerebrate

Pons Absent
fixed pauses or flaccid

Small,
Medulla Present Irregular Flaccid
reactive

INDONESIAN PEDIATRIC SOCIETY < 30 >

 E

INDONESIAN PEDIATRIC SOCIETY < 31 >

Assessment
◎ Stable!
◎ Respiratory Distress!
-  Impending respiratory failure!

-  Respiratory failure!
◎ Shock!
-  Compensated!

-  Uncompensated!
◎ Cardiopulmonary failure!

INDONESIAN PEDIATRIC SOCIETY < 32 >

• 
• 
Stabil
Pemeriksaan lengkap

Diagnosis
◎
•  Terapi < 33 >

•  Pemantauan
Gawat Napas
•  Biarkan di pangkuan
•  Biarkan posisi nyaman
◎
•  Oksigen < 34 >

•  Puasa

•  Pantau
 Gagal Napas
• 
• 
• 
Pisahkan dari pengasuh
Buka jalan napas
Oksigen
◎
•  Ventilasi < 35 >

•  Puasa
•  Akses vaskular
•  Pantau
 Renjatan
• 
• 
Pertahankan pernapasan

Oksigen
◎
•  Akses vaskular < 36 >

•  Cairan resusitasi

•  Pantau
 Gagal Napas

◎
& Sirkulasi
•  Pertahankan pernapasan
•  Bantuan napas
•  Bila perlu pijat jantung < 37 >

•  Akses vaskular
•  Cairan dan obat resusitasi

•  Evaluasi berulang
Secondary Assesment

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 Organ System Approach
Initial Examination after Transfer to PICU

- CNS system: Is the patient sedated/anesthetized, pupillary reflex, spontaneus

movements and breathing?
- Respiratory system: Is the chest moving? How are thorax/chest movement?
Symmetrical? Adequate expansion? SpO2? FiO2?
- Cardiovascular system: Palpation of central/peripheral pulses (femoral,
brachial), visual check of hemodynamic parameter (CVP/ABP/NIBP), CRT, UO
- Metabolic system: Fluid balance? Does the patient appear oedematous (puffy)
or rather dehydrated?
- Immunity and Infection system: Body temperature, assessment of catheters,
lines and cables inserted
- Hematology system: Does the urine look clear or hemolytic? Are the drains
connected to suction? How much in the bag and how quick is it filling? Are the
fluids dark red (venous blood), bright red (arterial blood), yellowish or clear
(serous), warm (fresh) or cold (older)?
- Nutritional status: How long should the patient fast? TPN?

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 Respiratory System
Failure of Breathing Examples
Failure of neural control Uncal herniation, central
hypoventilation

Failure of muscles of Insufficient muscle blood
breathing flow, hypoxemia

Failure of mechanics of Flail chest, diaphragmatic

breathing paralysis

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 Causes of Muscle Failure
Mechanism Examples
Overwork Lung dysfunction, airway
obstruction

Inadequate substrate Shock, hypoxemia

Muscle plegia Hypokalemia

Muscle tetany Tetanus, hypocalcemia

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 Abnormalities in PETCO2
Increases in PETCO2 Decreases in PETCO2
Sudden Sudden
Sudden increase in CO Sudden hyperventilation
Release of a tourniquet Sudden decrease in cardiac output
Injection of Sodium Bicarbonate Massive pulmonary embolism
Gradual Air embolism
Hypoventilation Ventilator disconnection
Increased metabolism - CO2 production Ventilator circuit leakage
Obstruction of the ET tube
Absent PETCO2 Gradual
Esophageal intubation Hyperventilation
Accidental extubation Decrease in metabolism – CO2 production
Decrease in pulmonary perfusion

Tobin M. Respiratory monitoring. JAMA. 1990;264:244-251.

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Non Invasive Ventilation

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 Key Points

➢ Quick Look assessment using “Paediatric Assessment

Triangle” is a rapid way to decide if a child is severely ill
or not and if they require immediate lifesaving
treatment & additional resources
➢  Increased work of breathing with normal behaviour
and body colour indicates respiratory distress
➢  Abnormal body colour (perfusion) and abnormal
behaviour without increased work of breathing
indicates patient is in shock states

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➢  Abnormal behaviour without increased work of
breathing and decreased skin perfusion might
happened in primary CNS problem or metabolic
problem or intoxication
➢  BBB à ABCDE
➢  When a potentially life threatening problem is
identified, immediate treatment is performed before
moving on to the next step à Treat as you go!
➢  Assess and Reassess

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Upper airway obstruction:
When to suspect?

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 Sign and symptom
Symptom : Signs :
-  Stridor
-  Nasal blockage -  Abnormal voice
-  Snoring -  Confusion
-  Shortness of - Restlessness
-  Cyanosis
breath
- Use of acessory
-  Coughing muscle
-  Chocking - Suprasternal
recession

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 Stridor

•  Is a physical sign common to all causes of upper

airway obstruction

•  It is a harsh, raspy noise produced by the flow of

air through partially obstructed airway

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How to manage the upper
airway obstruction ?

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Algorithm for management of acute upper airway obstruction

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Indian J Pediatr.82(8):737-44.2015 >
Foreign body airway obstruction or
chocking

•  A common cause of upper airway obstruction < 3

years of age

•  Management depend on the effectiveness of cough

and level of consciouness

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FBAO algorithm

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Heimlich maneuver

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 Summary

•  The priority in acute obstruction should always be

securing of the airway either medically or surgically
followed by treatment of the underlying cause

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Thank You

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