Recognition of

Early Signs of Critical Illness

in Children
Introduction
100%

Survival
rate 50%

0%
Respiratory Cardiopulmonary
failure arrest
Primary/Initial Assessment

Pediatric Assessment Triangle :

W
ce

or
an

ko
ar

fB
pe

rea
Ap

th
ing
Circulation to Skin

3
 Appearance (“Tickles” =TICLS)

• Tonus

ce
• Interactiveness

n
ara
• Consolability

pe
Ap
• Look/Gaze
• Speech/Cry

4
 Work of Breathings
Wo
rk
of • Abnormal airway sounds
• Abnormal positioning
Br
eat

• Retractions
hin

• Nasal flaring
gs

5
Inspiratory Stridor
Head Bobbing
Abnormal positioning

Sniffing
Tripod posture
retraction
 Circulation to Skin

Characteristic of Circulation to Skin

• Pallor
• Mottling
• Cyanosis
PAT: Potential Respiratory Failure

W
or
ce

ko
an
Normal ar

fB
pe

rea
Ap

th
ing
Circulation to Skin
Normal

UKKPGD-IDAI 2001
 PAT: Respiratory Failure

W
or
ce
Abnormal

ko
an
ar Or

fB
pe

rea
Ap

th
ing
Circulation to Skin

Normal or Abnormal

UKKPGD-IDAI 2001
 PAT: Shock

W
or
ce
Abnormal

ko
an
Normal
ar

fB
pe

rea
Ap

th
ing
Circulation to Skin

Abnormal
PAT: Primary Neurologic/Metabolic Disorder

W
or
ce
Abnormal

ko
an
Normal
ar

fB
pe

rea
Ap

th
ing
Circulation to Skin

Normal

14
 PHYSICAL EXAMINATION 
rapid assessment

• AIRWAY  ventilation
• BREATHING  oxygenation
• CIRCULATION  perfusion
• DISABILITY
• EXPOSURE
Airway

• Clear
• Maintainable
• Unmaintainable
 Obstructed
 Need intubation
 Breathing
• Respiratory rate  tachypnoe, bradypnoe
• Respiratory effort  dyspnoe
• Skin color
• Air entry
• Mental status
Age (year) Respiratory rate (x/mnt)

<1 30 - 40

1-5 20 - 30

5 - 12 15 - 20

> 12 12 - 16
 Circulation
• Heart rate: tachycardia?bradycardia?
• Perfussion: skin themperature, CRT, skin
color (mottled, cyanosis, pale)
• Blood pressure
Age Heart rate (x/mnt)
Neonate – 3 months 85 – 200
3 months – 2 years 100 – 190
2 – 10 years 60 – 140
 Circulation pulse quality
• Normally the brachial pulse is palpable inside or medial to the
biceps (weak / strong)  if strong probably not hypotensive
• If peripheral pulse not palpated, check the central pulse
(femoral / carotid)
• Absent of a central pulse  CPR
 Skin Temperature
Capillary Refill Time
• Circulation to the skin (skin temp., capillary refill
time, pulse quality)  assessment circulatory status
• Capillary refill time (N 2-3 seconds), affected by
environmental factors  cool room temp
Minimal systolic blood pressure
Age Minimal SBP (5th percentile)

0 – 1 month 60

> 1 month – 1 year 70

> 1 year 70 + (2 x age)

 Disability:
neurologic status

• Cortex
• Brainstem
• Motoric
 conciousness
A: Awake
V: Responsive to VOICE
P: Responsive to PAIN
U: Unresponsive
Brain Stem

• Posture
• Respiration
• Refleks
• Cranial nerve
 Motoric Activity
• Asymmetric movement
• Convulsion
• Position
• Flaccidity
Exposure
• Hematoma
• Rash
• Icteric
 Physiological Status
(Classification)

STABLE

RESPIRATORY DISTRESS

RESPIRATORY DYSFUNCTION
RESPIRATORY FAILURE

COMPENSATED
SHOCK
DECOMPENSATED

CARDIORESPIRATORY FAILURE
Management of stable patient

• Examination
• Diagnosis
• Planning  Spesific management
 Management of Respiratory dysfunction

Respiratory ditress Respiratory failure

With his/her caregiver Separate from his/her caregiver

Comfort position

Oxygen Secured airway, 100% Oxygen ,

ventilatory support

NPO NPO

Closed monitor Closed monitor, vascular access

 Management of shock
• Airway
• Breathing: oxygen
• Vascular access
• Fluid
• Monitoring  HR, oxygenation, urine
production
• Need vasoactive agent?
 Summary
• An initial assessment allows an evaluation of
severity and urgency for treatment
• The PAT and ABCDE  good tool for rapid
assessment
• Classification  spesific management 
survival rate ↑
Question ?