Chapter 12

ASSESSMENT & MANAGEMENT OF THE ACUTELY ILL INFANT OR CHILD

When faced with a seriously ill or injured child, a systematic approach and rapid determination of the child's physiologic status with concurrent initiation of resuscitative measures is imperative. Initial management must be directed at correcting any physiologic derangement. Specifically, one must evaluate the airway for any obstruction, assess ventilatory status, and evaluate for shock. Intervention to correct any abnormalities in these three parameters must be undertaken immediately. Following this initial intervention, the provider must then carefully consider the underlying cause, focusing on those that are treatable or reversible. Specific diagnoses can then be made, and targeted therapy (eg, intravenous [IV] glucose for hypoglycemia) can be initiated.

Pediatric cardiac arrest more frequently represents progressive respiratory deterioration or shock, also called asphyxial arrest, rather than primary cardiac etiologies. Unrecognized deterioration may lead to bradycardia, agonal breathing, hypotension, and ultimately asystole. Resulting hypoxic and ischemic insult to the brain and other vital organs make neurologic recovery extremely unlikely, even in the doubtful event that the child survives the arrest. Children who respond to rapid intervention with ventilation and oxygenation alone or to less than 5 minutes of advanced life support are much more likely to survive neurologically intact. In fact, more than 70% of children with respiratory arrest who receive rapid and effective bystander resuscitation survive with good neurologic outcomes. Therefore, it is essential to recognize the child who is at risk for progressing to cardiopulmonary arrest and to provide aggressive intervention before asystole occurs.

When cardiopulmonary arrest does occur, survival is rare and most often associated with significant neurological impairment. Current data reflect a 6% survival rate for out-of-hospital cardiac arrest, 8% for those who receive prehospital intervention, and 27% survival rate for in-hospital arrest.

The following discussion details care of the critically ill pediatric patient who does not require cardiopulmonary resuscitation (CPR). Detailed information regarding the 2010 Guidelines for Pediatric Basic (BLS) and Advanced Life Support (PALS) can be found under Statements & Guidelines at http://myamericanheart.org/professional. Note: Standard precautions (personal protective equipment) must be maintained during resuscitation efforts.

THE ABCs OF RESUSCITATION

Any severely ill child should be rapidly evaluated in a deliberate sequence of airway patency, breathing adequacy, and circulation integrity. Derangement at each point must be corrected before proceeding. Thus, if a child's airway is obstructed, the airway must be opened (eg, by head positioning and the chin lift maneuver) before breathing and circulation are assessed.

Airway

Look for evidence of spontaneous breathing effort. Adventitious breath sounds such as stridor, stertor, or gurgling, or increased work of breathing without air movement is suggestive of airway obstruction. Significant airway obstruction often is associated with altered level of consciousness, including agitation or lethargy. During this rapid assessment, if the patient is noted to be apneic or ...

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