There are few situations that provoke greateranxiety than being called to see a child who isseriously ill. This chapter outlines a basic approachto the emergency management of seriously illchildren.

The seriously ill child

The rapid clinical assessment of the seriously illchild will identify if there is potential respiratory,circulatory or neurological failure. This should takeless than 1 minute. Normal vital signs are shown inFigure 6.1 and how a rapid assessment is performed in Figure 6.2. Resuscitation is given immediately ifnecessary, followed by secondary assessment andother emergency treatment.

The seriously ill child may present with shock,respiratory distress, as a drowsy/unconscious orfitting child or with a surgical emergency. Theircauses are listed in Figure 6.4. In children, the key tosuccessful outcome is the early recognition andactive management of conditions that are life-threatening and potentially reversible.

Paediatricemergencies

6

Regarding the seriously ill child:• prevention of cardiopulmonary arrest is by early

recognition and treatment of respiratorydistress, respiratory or circulatory failure.

Summary

Respiratory rate

Heart rate

Systolic blood pressure

Olderchildren

25 20

Olderchildren

120 80

Infants

9070Young

children

80Older children

11090

Youngchildren

30 25Infants

40 30

Youngchildren

140 95Infants

160 110

100

Vital signs

The seriously ill child 71Cardiopulmonary resuscitation 72

The seriously injured child 76Shock 76

The febrile child 78Septicaemia 80

Coma 80Status epilepticus 83

Anaphylaxis 84Apparent life-threatening events 84

The death of a child 84

Figure 6.1 Variation in the normal range for respiratoryrate, heart rate and systolic blood pressure with age.

Doctors should be able to provide lifesupport for children of all ages, fromnewborn to adolescents.

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Cardiopulmonary resuscitation

In adults, cardiopulmonary arrest is often cardiac in origin, secondary to ischaemic heart disease. Incontrast, children usually have healthy hearts butexperience hypoxia from respiratory or neurolo-gical failure or shock. If this occurs, irrespective of the cause, basic life support must be startedimmediately.

Basic life support (Fig. 6.5)

Advanced life support (Fig. 6.6)

Children who have been resuscitated successfullyshould be transferred to a paediatric high-dependency or intensive care unit.

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The rapid clinical assessment:ABCDEShould take < 1 min

Airway and BreathingLook, listen and feel for:Airway obstruction or respiratory distressWork of breathing (respiratory effort)Respiratory rateStridor, wheezeAuscultation for air entryCyanosis

CirculationFeel and assess:Heart ratePulse volumeCapillary refill time (Fig 6.3)Blood pressure

DisabilityObserve and note:Level of consciousness (Box 6.1)Posture – hypotonia, decorticate, decerebratePupil size and reactivity

Exposure

Secondary assessment

Includes Basic/Advanced life supportConsider:Jaw and neck positioningOxygenSuction and foreign body removalSupporting breathingChest compressionMonitoring pulse oximetry and heart rate

History from:• parents• witnesses• general practitioner• paramedical staff• policeExamination including:• evidence of trauma• rash, e.g. meningococcal• smell, e.g. ketones, alcohol• scars, e.g. underlying congenital heart disease• MedicAlert braceletInvestigations• blood glucose

Other emergency interventions

Resuscitation (if necessary)

Assessment of the seriously ill child

Press on the skin of the sternum or a digit atthe level of the heartApply blanching pressure for 5 secondsMeasure time for blush to returnProlonged capillary refill if >2 seconds

Capillary refill time

Figure 6.3 Capillary refill time. Digital pressure for 5seconds. Normal <2 seconds.

Capillary refill time is affected by bodyexposure in a cold environment.

Figure 6.2 Assessment of the seriously ill child.

Box 6.1 AVPU rapid assessment of level ofconsciousness – more detailed evaluation is with theGlasgow Coma Scale (see Table 6.2)

A ALERTV Responds to VOICEP Responds to PAINU UNRESPONSIVE

A score of P means that the child’s airway is at risk and will need tobe maintained by a manoeuvre or adjunct.

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Examples

Meningitis/encephalitis

Trauma/non-accidental injury

AppendicitisPeritonitis

CausePresentation

HypovolaemiaDehydration – gastroenteritis Diabetic ketoacidosisBlood loss – trauma

ShockMaldistribution offluid

SepticaemiaAnaphylaxis

CardiogenicArrhythmiasHeart failure

Respiratorydistress

Upper airway obstruction(stridor)

Croup/epiglottitisForeign bodyCongenital malformationsTrauma

Lower airway disorders

AsthmaBronchiolitisPneumoniaPneumothorax

Post ictal Status epilepticus

Infection

The drowsy orunconsciousor seizingchild

Metabolic

Diabetic ketoacidosis, hypoglycaemia,electrolyte disturbances (calcium,magnesium, sodium), inborn errorof metabolism

Head injury

Drug/poison ingestion

Intracranial haemorrhage

Acute abdomenSurgical emergencies

Intestinal obstructionIntussusceptionMalrotationBowel atresia/stenosis

Presentation and causes of serious illness in children

Figure 6.4 The main modes of presentation of serious illness in children and their causes.

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Basic life support

Open airway:• Head tilt, chin lift• Jaw thrust (if unsuccessful)

Check breathing for max 10 secs:• Look, listen, feel

No breathing

BreatheRemove any obvious obstructionGive 5 initial rescue breaths

No pulse or <60/min

No response

Compress chestRate: 100 compressions/minCompression: Ventilation ratio forall children:Two rescuers – 15:2Lone rescuer – 30:2

Shout for helpApproach with careFree from dangerEvaluate ABC

SAFE approach

Chin lift in infants• Head in neutral position• Avoid overextension• Remove secretions/foreign body under direct vision

Chin lift in childrenHead in 'sniffing' positionJaw thrustTwo fingers of each hand behindeach side of the mandible and pushthe jaw forward

AirwayAirway opening using head tilt/chin lift manoeuvre

BreathingInfant: Mouth over infant's nose and mouthChild: Pinch nose, mouth to mouthThe chest should rise with each breath

CirculationOptimal position for chest compression

a) Infant. Two thumbs on lower third of sternum with hands round the thorax (needs two rescuers).b) Small child. Heel of one hand over lower third of sternum.c) Large child. Both hands over lower third of sternum. Depress the sternum by onethird of the depth of the chest

Check responsiveness:Ask 'Are you all right?'StimulateDo not shake children withsuspected cervical spine injury

Check pulse for max 10 secs: >1 year old – carotid<1 year old – brachial

a

c

b

Figure 6.5 Basic life support. (Adapted from Resuscitation Guidelines, Resuscitation Council (UK), 2005.)

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Advanced life support

Establish Basic Life Support

Airway and BreathingIntubate and ventilate with highconcentration O2

CirculationOnce intubated:Compression rate 100/min continuouslyVentilation rate 10/minEstablish intravenous access, if delayuse intraosseous route

Internal diameter (mm) = (age/4) + 4Length for oral tube (cm) = (age/2) + 12Lengh for nasal tube (cm) = (age/2) + 15

Formula for endotracheal tube size by age in whole years

Technique to establish intraosseous infusion in the tibia• 18 gauge trochar with needle• Anterior surface, 2–3cm below tibial tuberosity

Shockable

Ventricular fibrillation(VF) or pulselessVentricular tachycardia (VT)

Attachdefibrillator/monitor

Assess rhythm

Non-shockable

Pulseless electrical activity(PEA) or asystole

1st DC shock 4 J/kg or AEDContinue CPR for 2 min

Check monitor - still VF/VT:2nd DC shock 4 J/kg or AEDResume CPR for 2 min

Check monitor - still VF/VT:Amiodarone 5 mg/kg IV4th DC shock 4 J/kg or AED

Resume CPR for 2 min cyclesGive epinephrine (adrenaline)before every other shock

Considerreversiblecauses

Check monitor - still VF/VT:Epinephrine (adrenaline)10 μg/kg (0.1 ml/kg of 1 in1000 solution) IV or IO3rd DC shock 4 J/kg or AEDResume CPR for 2 min

During CPR:Correct reversible causes:• Hypoxia• Hypovolaemia• Hypo/hyperkalaemia• Hypothermia <33 °C• Tension pneumothorax• Tamponade• Toxins• Thromboembolism

Check electrode position and contactEstablish IV/IO access

If automated external defibrillator (AED):• child 1–8 years – deliver paediatric-attenuated adult shock energy• child >8 years old – use adult shock therapy

Ventilate with highconcentration O2Continue CPR

Epinephrine (adrenaline)10 µg/kg (0.1 ml/kg of 1 in1000 solution) IV or IO

Consider reversiblecauses andalkalisingagents

Continue CPRRepeat epinephrine(adrenaline) every 3–5 min

Figure 6.6 Advanced life support. (Adapted from Resuscitation Guidelines, Resuscitation Council (UK), 2005.)

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The seriously injured child

Management of the seriously injured child musttake account of potential injury to the cervical spineand other bones and internal injuries (Fig. 6.7).

Shock

Shock is present when the circulation is inadequateto meet the demands of the tissues. Critically ill

children are often in shock, usually because ofhypovolaemia due to fluid loss or maldistributionof fluid, as occurs in sepsis or intestinal obstruction.

Why are children so susceptible to fluidloss?

Children normally require a much higher fluid intakeper kilogram of body weight than adults (Table 6.1).This is because they have a higher surface area tovolume ratio and a higher basal metabolic rate.Children may therefore become dehydrated if:

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Management of the seriously injured child

Primary survey

Secondary survey (once condition stabilised)

Airway andcervicalspine

Assume cervical spine damageNeck movements may injure spine

Only use jaw thrust and chin lift to open airwayNo neck extensionSecure neck with rigid cervical collar and sandbagsDiscontinue immobilisation only after cervicalspine X-rays and neurological examination arefound to be normal

Breathing Give high-flow O2 via face mask.If inadequate commence ventilation

Asymmetry of percussion note or breath sounds• consider: pneumothorax or haemothorax, which need to be drained immediately, misplaced endotracheal tube

Disability

Assess consciousness

Secure airwayProvide respiratory support if GlasgowComa Scale < 8 or at ‘P’ on AVPU scale

Assess pupil size and reactivity If unequal or abnormal – serious headinjury

Exposure

Examine all parts of bodyConsider analgesiaConsider gastric tube (not nasaltube in head injury)

Remove all clothingAvoid hypothermia and embarrassment!

ExaminePerform furtherinvestigations

Circulationandhaemorrhagecontrol

Bleeding from superficial wound?

If in shock, is there internal bleeding?Consider X-rays of chest and pelvisShock does not occur from isolatedhead injury beyond infancy

Apply pressure to stop bleeding.

Insert two large venous cannulaeTake blood for FBC, group and cross-matchGive crystalloid 20 ml/kg and reassessSeek surgical opinion, as likely to be rupturedliver, spleen or fractured pelvis or longbone

Identify all injuriesProvide emergencytreatment and definitivecare

Figure 6.7 Management of the seriously injured child.

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• they are unable to take oral fluids• there are additional fluid losses due to fever,

diarrhoea or increased insensible losses (e.g. due toincreased sweating or tachypnoea)

• there is loss of the normal fluid-retainingmechanisms, e.g. burns, the permeable skin ofpremature infants, increased urinary losses orcapillary leak.

Clinical features

The clinical features of shock are due to compen-satory physiological mechanisms to maintain thecirculation and the direct effects of poor perfusionof tissues and organs (Box 6.2). In early, com-pensated shock, the blood pressure is maintainedby increased heart and respiratory rates, re-distribution of blood from venous reserve volumeand diversion of blood flow from non-essentialtissues such as the skin in the peripheries, whichbecome cold. In shock due to dehydration, there isusually >10% loss of body weight (see Ch. 13) and aprofound metabolic acidosis and it is compoundedby failure to feed and drink whilst severely ill. Afteracute blood loss or redistribution of blood volumebecause of infection, low blood pressure is a latefeature. It signifies that compensatory responses are failing. In late or uncompensated shock,compensatory mechanisms fail and blood pressurefalls and lactic acidosis increases. It is important torecognise early, compensated shock, as this isreversible, in contrast to uncompensated shock,which may be irreversible.

Management priorities

Fluid resuscitationRapid restoration of the intravascular circulatingvolume is the priority (Fig. 6.8). This will usually bewith 0.9% saline, or blood if following trauma.

Subsequent management

If there is no improvement following fluid resus-citation or there is progression of shock andrespiratory failure, a paediatric intensive care unitshould be involved and transfer arranged as thechild may need:

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Shock

0.9% saline or blood(20 ml/kg)

Improvement

Correction ofhypovolaemia

x2 if necessary

No improvement

Intensive care

Shock in children:• is often from hypovolaemia• the early signs of compensated shock are from

increased sympathetic tone – tachycardia, pallorand peripheral vasoconstriction (prolongedcapillary refill time); its recognition is importantas at this stage it is reversible

• fluid therapy is the key to its successfultreatment.

Summary

Box 6.2 Clinical signs of shock

Early (compensated) Late (decompensated)Tachypnoea Acidotic (Kussmaul) Tachycardia breathingDecreased skin turgor BradycardiaSunken eyes and Confusion/depressed fontanelle cerebral stateDelayed capillary refill Blue peripheries(>2 s) Absent urine outputMottled, pale, cold skin HypotensionCore–peripheral temperature gap (>4°C)Decreased urinary output

Table 6.1 Fluid intake at different ages

Body weight Fluid requirement/24 h Volume/kg per hour (approximate)

First 10 kg 100 ml/kg 4 ml/kgSecond 10 kg 50 ml/kg 2 ml/kgSubsequent kg 20 ml/kg 1 ml/kg

Examples of calculationsWeight of child Fluid requirement/24 h Volume per hour (approximate)

Infant 7 kg 700 ml 28 ml/hChild 18 kg 1000 + 400 = 1400 ml 40 + 16 = 56 ml/hAdolescent 62 kg 1000 + 500 + 840 = 2340 ml 40 + 20 + 42 = 102 ml/h

Figure 6.8 Initial fluid resuscitation in shock.

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• tracheal intubation and mechanical ventilation• invasive monitoring of blood pressure• inotropic support• correction of haematological, biochemical and

metabolic derangements• support for renal or liver failure.

The febrile child

Most febrile children have a brief, self-limiting viral infection. Mild localised infections, e.g. otitismedia or tonsillitis, may be diagnosed clinically.The clinical problem lies in identifying therelatively few children with a serious invasivebacterial infection which needs prompt treatment.

Factors which need to be considered are:

• past medical history• illness of other family members• if a specific illness is prevalent in the community

• immunisation status• recent travel abroad, e.g. malaria, typhoid• contact with animals, e.g. brucellosis• predisposition to infection, e.g. nephrotic

syndrome, sickle cell disease, HIV infection,chemotherapy for malignant disease or, rarely, a primary immunodeficiency.

Initial assessment, investigations andmanagement

Some diagnostic clues to evaluating the febrile childare shown in Figures 6.9 and 6.10. Infants andtoddlers often present with non-specific signs. Ifthey are suspected of having a severe bacterial in-fection, urgent investigations called a septic screen(Box 6.3) are performed and intravenous antibiotictherapy given immediately to avoid the illnessbecoming more severe and to prevent rapid spreadto other sites of the body. In febrile infants less

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Upper respiratory tract infectionVery common, may be

coincidental with anothermore serious illness

Osteomyelitis or septicarthritisSuspect if painful bone or jointor reluctance to move limb

Otitis mediaAlways examine tympanic

membranes in febrile children

Periorbital cellulitisRedness and swelling of theeyelids.May spread to orbit of the eyeTonsillitis

Erythema or exudate onthe tonsils

RashViral exanthem?Purpura from meningococcalinfection (Fig.6.10)?

Abdominal painAppendicitis?Pyelonephritis?Hepatitis?

PneumoniaIn infants, only raised

respiratory rate andincreased respiratory effort

may be present, with noabnormality on

auscultation – diagnosis may require chest x-ray

DiarrhoeaGastroenteritis?Fever with blood and mucusin the stool:Shigella, Salmonella orCampylobacter

Urinary tract infectionUrine sample needed for anyseriously ill young childor any febrile illness that doesnot settle

SeizureFebrile convulsion?Meningitis?Encephalitis?

SepticaemiaCan be difficult to recognise in

absence of rash before shockdevelops.

Need to start antibioticson clinical suspicion without

waiting for culture results

Meningitis/encephalitisLethargy, loss of interest in

surroundings, drowsiness orunconscious or seizures.

Neck stiffness, arching of the back,bulging fontanelle, positive

Kernig’s sign (pain on legstraightening)?

Only non-specific symptoms andsigns may be present in young

children < 18 months

Prolonged feverBacterial infection e.g. UTI,bacterial endocarditisOther infections – viral, fungal,protozoalKawasaki's diseaseDrug reactionMalignant diseaseConnective tissue disorder

StridorEpiglottitis?Viral croup?

Bacterial tracheitis?

The febrile child

Figure 6.9 Some diagnostic clues to evaluating the febrile child.

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than 2 months old, identifying serious bacterialinfection is unreliable from clinical examinationalone, and a septic screen and antibiotic therapy are indicated. Other factors which influence theselection of which children to investigate and treatare shown in Figure 6.11. Children who are notseriously ill can be managed at home with regularreview by the parents as long as they are given clearinstructions (e.g. what clinical features shouldprompt reassessment by a doctor).

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Box 6.3 Septic screen

Full blood count including differential white cellcountBlood cultureAcute-phase reactant, e.g. C-reactive proteinUrine for microscopy, culture and sensitivityCSF (unless contraindicated) for microscopy,culture and sensitivityChest X-ray

Threshold for urgentinvestigation(septic screen) andintravenous antibiotics Low

High

Factors indicativeof illness severity

Young age (treat if <2 months old)Systemically ill

High or prolonged feverFeatures of potentially serious illness

e.g. osteomyelitis, septic arthritis,septicaemia, meningitis/encephalitis

No localising featuresPredisposition to infection

e.g. immunodeficiency

Older childNot systemically ill

Low grade feverNo features of potentially

serious illnessLocalised, minor illness,e.g. URTI, otitis media

Normal child

The febrile child:• upper respiratory tract infection (URTI) is an

extremely common cause• check for otitis media• serious bacterial infection must be considered• if fever in an infant is unexplained, exclude a

urinary tract infection• the younger the child the lower the threshold

for performing a septic screen and startingantibiotics.

SummaryFigure 6.10 The glass test for meningococcal purpura.Parents are advised to suspect meningococcal disease iftheir child is febrile and has a rash that does not blanchewhen pressed under a glass. (Courtesy of Dr ParvizHabibi.)

Figure 6.11 Evaluation of the need for urgent investigation and treatment in the febrile child.

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Septicaemia

Bacteria may cause a focal infection or proliferate in the bloodstream, leading to septicaemia. Insepticaemia, the host response includes the releaseof inflammatory cytokines and activation of endo-thelial cells which may lead to septic shock. Thecommonest cause of septic shock in childhood ismeningococcal infection, which may or may not be accompanied by meningitis. Fortunately, itsincidence in the UK has fallen markedly sinceimmunisation was introduced. Pneumococcus is thecommonest organism causing bacteraemia, but it is unusual for it to cause septic shock. In neonates,the commonest causes of septicaemia are group Bstreptococcus or Gram-negative organismsacquired from the birth canal.

Clinical features

See Box 6.4.

Management priorities

Children with septic shock will need to be rapidlystabilised and may require transfer to a paediatricintensive care unit.

AntibioticsChoice depends on the child’s age and anypredisposition to infection.

FluidsSignificant hypovolaemia is often present, owing to fluid maldistribution, which occurs due to therelease of vasoactive mediators by host inflamma-tory and endothelial cells. There is loss of intra-vascular proteins and fluid which may occur due tothe development of a ‘capillary leak’ caused byendothelial cell dysfunction. Circulating plasmavolume is lost into the interstitial fluid. Centralvenous pressure monitoring and urinary catheter-isation may be required to guide the assessment offluid balance. Capillary leak into the lungs causespulmonary oedema, which may lead to respiratoryfailure, necessitating mechanical ventilation.

Circulatory supportMyocardial dysfunction occurs as inflammatorycytokines and circulating toxins depress myocardialcontractility. Inotropic support may be required.

Disseminated intravascular coagulation (DIC)Abnormal blood clotting causes widespread micro-vascular thrombosis and consumption of clotting

factors. If bleeding occurs, clotting derangementshould be corrected with fresh frozen plasma andplatelet transfusions.

SteroidsThere is no evidence that steroids are of benefit inseptic shock.

Coma

In coma, there is disturbance of the functioning of the cerebral hemispheres and/or the reticularactivating system of the brainstem. The level ofawareness may range from excessive drowsiness to unconsciousness. It is assessed by rapidly usingAVPU or the Glasgow Coma Scale (Table 6.2).

The immediate assessment of a child in coma isshown in Figures 6.12 and 6.13. The causes, clinicalfeatures and investigations of coma are listed inTable 6.3. In contrast to adults, most children have a diffuse metabolic insult rather than a structurallesion.

The history, examination and investigation ofcoma are directed towards the cause. Treatmentshould be directed to treatable causes, especiallyinfection.

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Box 6.4 Clinical features of septicaemia

History ExaminationFever FeverPoor feeding Purpuric rash Miserable (meningococcal Lethargy septicaemia)History of focal infection, e.g. Irritabilitymeningitis, osteomyelitis, Shockgastroenteritis, cellulitis Multi-organ failurePredisposing conditions, e.g. sickle cell disease, immunodeficiency

Septicaemia:• the most common cause of septic shock in

children is meningococcal disease• may occur without meningitis• early antibiotic therapy and fluid resuscitation

are life-saving• may need admission to paediatric intensive care

for multi-organ failure.

Summary

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Com

a

Primary assessmentand

resuscitation

Airway – is it secure?Breathing – is respiratory effort sufficient?Circulation – treat shock Disability – check blood glucose – AVPU or Glasgow Coma ScaleExposure – e.g. look for meningococcal purpuric rash

Secondary assessmentand

emergency treatment

Examination• Is there raised intracranial pressure – abnormal breathing, posture, pupils (Fig. 6.13), fundi (papilloedema or retinal haemorrhages)?• Bradycardia and hypertension suggest impending brain stem herniation

Treat the treatable:• hypoglycaemia• poisoning• diabetes mellitus• septicaemia/meningitis• herpes simplex encephalitis

Intubate and ventilate if necessary, transfer to paediatric/neurosurgicalintensive care unit

Initial assessment and management of coma

Pinpoint, fixedOpiates/barbituratesPontine lesion

Fixed, dilatedSevere hypoxiaDuring/post-seizuresAnticholinergic drugsHypothermia

Unilateral dilated pupilExpanding ipsilateral lesionTentorial herniationThird nerve lesionSeizures

Figure 6.12 Initial assessment and management of coma.

Table 6.2 Glasgow Coma Scale, incorporating Children’s Coma Scale

Glasgow Coma Scale Children’s Coma Scale(4-15 years) (<4 years)

Response Response Score

Eyes Open spontaneously Open spontaneously 4Verbal command React to speech 3Pain React to pain 2No response No response 1

Best motor responseVerbal command Obeys Spontaneous or obeys verbal command 6Painful stimulus Localises pain Localises pain 5

Withdraws Withdraws 4Abnormal flexion Abnormal flexion (decorticate posture) 3Extension Abnormal extension (decerebrate posture) 2No response No response 1

Best verbal response Oriented and converses Smiles, orientated to sounds, follows 5objects, interacts

Disoriented and converses Fewer than usual words, spontaneous 4irritable cry

Inappropriate words Cries only to pain 3Incomprehensible sounds Moans to pain 2No response No response to pain 1

A score of <8 out of 15 means that the child’s airway is at risk and will need to be maintained by a manoeuvre or adjunct.

Figure 6.13 Pupillary signs in coma.

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Table 6.3 Causes, history and examination, and investigation of coma

Cause History and examination Diagnostic investigations

InfectionMeningitis or Fever Full blood countmeningoencephalitis Irritability, lethargy, drowsiness Culture of blood, urine, infected sites,

Poor feeding CSF (unless contraindicated) for bacteria Rash, e.g. meningococcal purpura and virusesSeizures Acute-phase reactantOverseas travel Rapid bacterial antigen/PCR tests for

organisms

MetabolicDiabetes mellitus Previously diagnosed diabetes mellitus Blood glucose, plasma electrolytes

Diabetic ketoacidosis Urine for glucose and ketonesBlood gas analysis

Inborn errors of metabolism Previous history of loss of consciousness Blood glucoseSudden collapse Blood gas analysisConsanguinity Blood ammonia, lactateDevelopmental delay Urine amino and organic acidsDeath or illness of siblings Plasma amino acidsHepatomegaly

Hepatic failure Jaundice Abnormal liver function testsAbnormal bleeding Prolonged prothrombin time

Acute renal failure Oliguria Abnormal creatinineHypertension

Hypoglycaemia Any acutely ill child Low blood glucoseKnown diabetes mellitusSudden onset of coma

Poisoning Accidental – poison usually identified Toxicology screenDeliberate – tablets may be found, also Plasma level for paracetamol and illicit drugs and alcohol salicylates

Status epilepticus or Past history of seizures Blood glucosepost-ictal Neurocutaneous lesions on the skin Electrolytes – sodium, potassium, calcium,

Developmental delay magnesiumOngoing seizure activity, e.g. abnormal Drug levels if on anticonvulsantseye movements EEGFocal neurological signs CT scan

Trauma – accidental/ History of road traffic accident, fall, etc. Radiological – plain X-rays or CT/MRI scansnon-accidental Bruising, haemorrhage

Fractures – cervical spine, etc.Focal neurologyRetinal haemorrhages

Intracranial tumour or Raised intracranial pressure: Cranial CT/MRI scanhaemorrhage/infarct/ • headache worse on lying down Coagulation screenabscess • early morning vomiting Screen for procoagulant disorders (protein

• focal neurological signs, e.g. squint, C and S deficiency)ataxia Echocardiogram to exclude infective

• personality change endocarditis• papilloedema/retinal haemorrhage• hypertension

Hypertension Symptoms and signs of raised intracranial Left ventricular hypertrophy on ECGpressure or echocardiographyFundoscopy – hypertensive changes Creatinine and electrolytesHigh blood pressure

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Status epilepticus

This is a seizure lasting 30 minutes or longer, orwhen successive seizures occur so frequently that

the patient does not recover consciousness betweenthem. After immediate primary assessment andresuscitation, the priority is to stop the seizure asquickly as possible (Fig. 6.14).

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No response in10 min

Airway, Breathing, Circulation

Check blood glucoseIf blood glucose is <3 mmol/L, give glucose IV

and recheck blood glucose

Vascular access

IV access

No vascular access

No IV accessNo response in10 min

No response in 10 mincall for senior help

No response in5 min

Lorazepam 0.1 mg/kg IV

Lorazepam 0.1 mg/kg

Paraldehyde 0.4 ml/kg PR

Phenytoin 18 mg/kg IV/IO over 20 min orPhenobarbital 15 mg/kg if on oral phenytoin

Rapid-sequence induction with thiopentoneMechanical ventilation

Transfer to PICU

Stop fitting withanticonvulsant

All these drugs maycause or compound

preexisting respiratorydepression, and

mechanical ventilationmay be required

Call anaesthetist or intensivistNo response in 20 min

Diazepam 0.5 mg/kg PRor Midazolam (buccal) 0.5mg/kg

Management protocol for status epilepticus

Figure 6.14 Management protocol for status epilepticus. (Adapted from Advanced Paediatric Life Support, BMJPublishing Group, London, 2005.)

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Anaphylaxis

In children, the most common causes are ingestionor contact with nuts, egg, milk or drugs. Urticariaand angioedema causing facial swelling are treatedwith an oral antihistamine (e.g. chlorphenamine)and observed over 2 hours for possible complica-tions. Anaphylaxis is life-threatening, from laryn-geal oedema, brochoconstriction and shock. Itsmanagement is outlined in Figure 6.15. Childrenwho have had a serious allergic reaction shouldcarry an epinephrine (adrenaline) auto-injector (e.g.Epipen) with them so that treatment can be initiatedimmediately.

Apparent life-threatening events (ALTE)

These occur in infants and are a combination ofapnoea, colour change, alteration in muscle tone,choking or gagging, which are frightening to theobserver. They may occur on more than one occa-sion. ALTEs may be the presentation of a potentiallyserious disorder, although often no cause isidentified.

Management requires a detailed history andthorough examination to identify problems withthe baby or in care-giving. The infant should beadmitted to hospital. Causes and investigations tobe considered are listed in Box 6.5. Multi-channelovernight monitoring is usually indicated.

In most, the episode is brief, with rapid recovery,and the baby is well clinically. Baseline investiga-tions and overnight monitoring of oxygen satura-tion, respiration and ECG are found to be normal.The parents should be taught resuscitation and willfind it helpful to receive follow-up from a specialistpaediatric nurse and paediatrician.

Detailed specialist investigation and assessmentwill be required if clinical, biochemical or physiol-ogical abnormalities are identified.

The death of a child

The risk of death is four times greater duringinfancy than at any other age in childhood. In many,a serious condition will have been diagnosed beforeor after birth, such as a congenital abnormality orcomplications of prematurity. Deaths which occursuddenly and unexpectedly in infancy are knownas sudden unexpected death in infancy (SUDI). In some, a previously undiagnosed congenitalabnormality, e.g. congenital heart disease, will befound at autopsy. Rarely, an inherited metabolic

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History compatible with severe allergic reactionStridor, wheeze, respiratory distress or shock+/- urticaria

Evaluate ABCOxygen if available

Epinephrine (adrenaline) IM(If profound shock – consider slow IV infusion of epinephrine (adrenaline) wheeze)If stridor – consider inhaled epinephrine (adrenaline)salbutamol

Repeat epinephrine (adrenaline) IM in 5 minutesif no improvementIf shock – give 20 ml/kg IV fluids

Antihistamine (chlorphenamine) IMHydrocortisone IM or slow IV

Immediate management of anaphylaxis

Figure 6.15 Management of anaphylaxis.

Box 6.5 Causes and investigations to be consideredin apparent life-threatening events

Causes

Infections – respiratory syncytial virus (RSV),pertussisSeizuresGastro-oesophageal reflux (present in one-third ofnormal infants)Upper airways obstruction – natural or imposedNo cause identified

Uncommon

Cardiac arrhythmiaBreath-holdingAnaemiaHeavy wrapping/heat stressCentral hypoventilation syndromeCyanotic spells from intrapulmonary shunting

Investigations to be considered

Blood glucose (as soon as possible)Blood gas (as soon as possible)Oxygen saturation monitoringCardiorespiratory monitoringEEGOesophageal pH monitoringBarium swallowFull blood countUrea and electrolytes, liver function testsLactateUrine (collect and freeze first sample)– metabolic studies– microscopy and culture– toxicologyECG – for QTc conduction pathway abnormalityChest X-rayLumbar puncture

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disorder is identified, in particular the fatty acidoxidation defect medium-chain acyl-CoA dehydro-genase deficiency (MCAD), which can very rarelyresult in sudden death in infants, but is increasinglyidentified in the UK from routine biochemicalscreening (Guthrie test) as the test for this disorderis being introduced more widely. After 1 month ofage, in most instances of sudden and unexplaineddeath, no cause is identified and the death isclassified as sudden infant death syndrome (SIDS).The vast majority of such deaths, even whenoccurring several times in the same family, are dueto natural causes. Rarely, the death may be due tosuffocation or other forms of non-accidental injury. In 2003, in the UK, three mothers imprisonedafter the loss of more than one infant had theirconvictions overturned. This followed concernabout the standard of proof required from medicalexpert witnesses in the absence of eye witnessevidence of harmful conduct and about the qualityof the procedures adopted during the investigationof the deaths. Since then, new procedures have beenrecommended in order to prevent unwarrantedincrimination of parents whilst also protectingother infants and children in the family from risk ofinjury.

Sudden infant death syndrome

This is defined as the sudden and unexpected deathof an infant or young child for which no adequatecause is found after a thorough postmortemexamination. There is marked variation in theincidence of SIDS in different countries, suggestingthat environmental factors are important (Box 6.6).SIDS occurs most commonly at 2–4 months of age(Fig. 6.16). The risk for subsequent children isslightly increased.

In the UK, the incidence of SIDS has fallendramatically during the last few years (Fig. 6.17),coinciding with a national ‘Back to Sleep’ campaign(Fig. 6.18). This advocates that:

• infants should be put to sleep on their back (not their front or side)

• overheating by heavy wrapping and high roomtemperature should be avoided

• infants should be placed in the ‘feet to foot’position

• parents should not smoke near their infants

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The death

of a child

Box 6.6 Factors associated with SIDS (based on datafrom Fleming P et al, Sudden unexpected deaths ininfancy, The Stationery Office, London, 2000, withpermission)

The infant

Age 1–6 months, peak at 12 weeksLow birthweight and preterm (but 60% are normalbirthweight term infants)Sex (boys 60%)Multiple births

The parents

Low income*Poor or overcrowded housingMaternal age (mother aged <20 years has threetimes the risk of a mother aged 25–29 years, but80% of affected mothers are >20 years old)*Single unsupported mother (twice the rate ofsupported mothers)High maternal parity*Maternal smoking during pregnancy (1–9cigarettes/day doubles the risk: >20/day increasesthe risk fivefold)*Parental smoking after baby’s birth

The environment

The infant sleeps lying proneThe infant is overheated from high roomtemperature and too may clothes and covers,particularly when ill

*Three of these four factors are present in over 40% of SIDS but only8% of control families.

20

15

10

5

0

Age (months)

1 2 3 4 5 6 7 8 9 10 11 12

%

Figure 6.16 Age distribution of SIDS. (Based on datafrom Fleming P et al, Sudden unexpected deaths ininfancy, The Stationery Office, London, 2000, withpermission.)

Figure 6.17 Decline in the number of deaths from SIDSin the UK from 1.9/1000 live births in 1989 to 0.41 in2004.

Year

SID

s p

er 1

000

live

bir

ths

2

0

1.6

1.2

0.8

0.4

19901992

19941996

19982000

20022004

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• parents should seek medical advice promptly iftheir infant becomes unwell

• parents should have the baby in their bedroom forthe first 6 months of life

• parents should avoid bringing the baby into theirbed when they are tired or have taken alcohol,sedative medicines or drugs

• parents should avoid sleeping with their infant ona sofa, settee or armchair.

Following the sudden death of a child

The sudden death of a child is one of the mostdistressing events that can happen to a family. Ifclose family members are absent, arrangementsshould be made for them to come, if this is possible.The family should be spoken to sympatheticallyand in private (see Ch. 5). An outline of therecommended management after an infant has died suddenly and unexpectedly is shown in Figure 6.19.

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6Paediatric em

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encies

Following an unexpected death:• the parents should be offered the opportunity

to see and hold their child• the coroner must be informed and a

postmortem performed• the parents should be informed about the

postmortem, that investigations will beperformed and that the police will be involvedand reassured that this is standard practice

• follow-up and bereavement counselling shouldbe offered.

Summary

°C

40

30

20

10

-10

0

Lie infant on back Do not smoke during pregnancy orin the same room as infant

No. of cigarettes smoked/day20 plus

x10

x8

x6

x4

x2

010-191-9

Incr

ease

in ri

sk o

f SID

S

Avoid overheating Place in ‘feet to foot position’

Keep head uncovered

Hot

Cold

Comfortable(16-20°C)

Prevention of sudden infant death syndrome

Sudden infant death syndrome (SIDS):• is the commonest cause of death in children

aged 1 month to 1 year• the peak age is 2–4 months• has been dramatically reduced by lying babies

on their back to sleep.

Summary

Figure 6.18 Key features of the ‘Backto Sleep’ campaign.

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87

The death

of a child

ResuscitationInfant found dead at home – take to Accident and Emergency DepartmentInitiate resuscitation unless inappropriate

Care ofparents

Should be cared for by specific member of staffHistory should be obtained

Babypronounced dead

Detailed clinical examination by consultantRemove endotracheal tube and intraosseous needles but retain venous linesRetain child's clothes and any bedding and nappy for policeInvestigations performed:• Nasopharyngeal aspirate for virology and bacteriology• Blood for toxicology, metabolic screen (on Guthrie card), chromosomes if dysmorphic• Blood culture • Urine (catheter specimen) – for biochemistry, toxicology and freeze immediately• Lumbar puncture – CSF for virology and routine culture, if clinically indicatedSUDI paediatrician, coroner, police and primary care team and other healthcare professionalsinformed

Performed by the paediatrician. Explain that the police and coroner will be involved,a post-mortem is required, tissue blocks and slides will be taken and retained permanentlyas part of the medical record.Give parents the opportunity to donate tissues and organsInform them that the involvement of the police does not imply that they are beingblamed for their child's death

Parents should be offered the opportunity to see and hold their child. Encourage as helpsthem accept the reality of their child's death. They may wish to see the child again withinthe next few days. The family may wish a minister of religion to be called.

Initial strategydiscussion

SUDI paediatrician and supervising police officerSocial services review to identify if previously involved or any child protection issues

Home visitwithin 24 hours

Police visit the home to talk with the parents and examine the place where the baby diedSUDI paediatrician may also attendDetailed history obtainedReport compiled for the coroner

Post-mortem Performed by paediatric pathologistPreliminary post-mortem result

Case discussion

Multi-agency meeting, including SUDI paediatrician, police, GP/health visitor and,where appropriate, the social workerAll relevant information reviewedPossibility of abuse or neglect consideredReport is sent to the coronerPaediatrician writes a detailed letter to the parents providing information about thecause of the infant's death and arranges to meet them

Follow-up andbereavementcounselling

Follow-up to provide family an opportunity to discuss the final results of the postmortemand consider its implications for future pregnancies. Genetic counselling may be indicated.Bereavement counselling – available from health professionals and other agencies

Breaking thenews to theparents

Parents offeredto see and holdtheir baby

Management of the sudden unexpected death of an infant

Figure 6.19 A recommended approach to the management of the sudden unexpected death of an infant. There arelocal variations in its implementation. (Adapted from Sudden Unexpected Death in Infancy. RCPCH, London, 2004.)

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Further reading

Goldman A, Hain R, Lieben S 2005 The Oxfordtextbook of palliative care in children. OxfordUniversity Press, Oxford. Medical, psychological andpractical issues of caring for terminally ill children andtheir families

Advanced Life Support Group 2005 AdvancedPaediatric Life Support. The Practical Approach, 4th Edn. Blackwell BMJ Books

RCPCH 2004 Sudden unexpected death in infancy.The report of a working group convened by the RoyalCollege of Pathologists and The Royal College ofPaediatrics and Child Health. RCPCH, London(www.rcpath.org and www.rcpch.ac.uk).

Resuscitation Council (UK) 2005 Updated guidelineson paediatric life support

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