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Chapter 2 Assessing Children and the Elderly

Recognition of the Sick Child

Early identification of seriously ill children is vital as they competence well then tend to crash.
Therefore A rapid initial assessment and primary survey should be performed to
identify life-threatening problems

General
Impression
A useful ‘door step’
or ‘end of bed’ assessment tool is the Paediatric Assessment
Triangle this
can be undertaken as you approach the child. This is derived
from (PEPP) Paediatric
Education for Pre-hospital Professionals by AAP

Airway &
Appearance (Open/Clear – Muscle Tone /Body Position)


What’s
Abnormal
:

Abnormal
or absent cry or speech.Decreased
response to parents or environmental stimuli.Floppy
or rigid muscle tone or not moving.


What’s
Normal
:
Normal
cry or speech.Responds
to parents or to environmental stimuli such as lights, keys, or
toys.Good
muscle tone. Moves
extremities well.


Breathing, Work of
(Visible movement / Respiratory Effort)


W
hat’s
Abnormal
: Increased/excessive
(nasal flaring, retractions or abdominal muscle use) or decreased/absent
respiratory effort or noisy breathing.


What’s
Normal
:
Breathing
appears regular without excessive respiratory muscle effort or audible
respiratory sounds.

Circulation to Skin
(Colour / obvious bleeding)


What’s
Abnormal
:

Cyanosis,
mottling, paleness/pallor or obvious significant bleeding.


What’s
Normal
:

Colour
appears normal for racial group of child. No significant
bleeding.


Initial
Assessment
Airway &
Appearance (Open/Clear – Mental Status)
·        
Look & listen
for possible obstructions.
·        
Inspiratory stridor
is indicative of upper airway obstruction.
·        
Wheezing indicates
obstruction of the lower airways.
·        
Volume does not
indicate severity
·        
Do not attempt blind
finger sweeps.
·        
Newborn &
infants – neutral alignment.
·         Avoid hyperextension
in young children.


What’s
Abnormal
:

Obstruction
to airflow.Gurgling,
stridor or noisy breathing.Verbal,
P
ain, or Unresponsive on AVPU
scale.


What’s
Normal
:

Airway
clear and maintainable. Alert on AVPU
scale.


Breathing (Effort /
Sounds / Rate / Central Colour)
Assess the rate,
effort and effectiveness of breathing 1.   
Assess the
respiratory rate:



Age Respiratory Rate
<1 year 30-40 breaths per minute
1-2 years 25-35 breaths per minute
2-5 years 25-30 breaths per minute
5-11 years 20-25 breaths per
minute


Clinical Practice Guidelines 2006 (JRCALC)2.   
Assess the amount of
effort being used to breathe:Are there any
inspiratory or expiratory noises such as stridor, wheeze or
grunting?Can you see
accessory muscles being used?Is sternal recession
evident?Are the nostrils
flared? 3.    Assess the
effectiveness of breathing:Listen to breath
sounds (auscultate) and measure the oxygen saturation levels to assess the
effectiveness of breathing.


What’s
Abnormal
:

Presence
of retractions, nasal flaring, stridor, wheezes, grunting, gasping or gurgling.
Respiratory
rate outside normal range. Central cyanosis.


What’s
Normal
:
Easy, quiet
respirations. Respiratory rate within normal range. No central
cyanosis.


Circulation (Pulse
Rate & Strength / Extremity Color & Temperature / Capillary Refill /
Blood Pressure)

1.    Assess the heart
rate:


Age Heart Rate
<1 year 110-160 beats per minute
1-2 years 100-150 beats per minute
2-5 years 95-140 beats per minute
5-11 years 80-120 beats per
minute

Clinical Practice
Guidelines 2006 (JRCALC)

2.    Assess the pulse
volume – absent peripheral pulses and weak central pulses are signs of advanced
shock. The
presence of certain peripheral pulses can not be used to
estimate systolic blood pressure in children.


3.    Assess the capillary
refill using the forehead, sole of foot or sternum.


4.   
Blood Pressure – should not be routinely measured in pre-hospital
care because:
It varies with
age
It is maintained
until shock is very severe
   
Hypotension
is a pre-terminal sign

Age Lower Limit of Normal Systolic BP
<1 year >60 or Strong Pulses
1-3 years >70 or Strong Pulses
4-5 years >75
6-12 years >80
13-18 years >90


What’s Abnormal:
Cyanosis,
mottling, or pallor. Absent or weak peripheral or central pulses; Pulse or
systolic BP outside normal range; Capillary refill > 2 sec with other
abnormal findings.


What’s
Normal
:
Colour
normal. Capillary refill at palms, soles, forehead or central body ≤
2 sec.
Strong peripheral and central pulses with regular rhythm.


Fluid Loss
(Hypovolaemic
)
Shock
in
Children

Signs <25% Blood Loss 25-40% Blood Loss >40% Blood Loss
Heart Rate Increased Increased Increased or Reduced
Systolic BP Normal Normal or Reduced Reduced ++
Pulse Volume Normal or Reduced Reduced Reduced ++
Cap Refill Normal or /ncreased Increased Increased
Resp Rate Increased Increased Sighing
Skin Temp Cool Cold Cold
Skin Colour Pale Mottled White/Grey
Mental State Mild agitation Drowsy Reacts to pain only

Remember:
A child with >25%
shock needs blood & urgent hospital care


Disability
1.    Assess levels of
consciousness – AVPU (Modified
GCS during
secondary survey)

 

 

                                                                                  
Glasgow Coma Scale for Children <4 Years

 

Glasgow coma scale (<4
years)
 
Response Score
Eye Opening  
Spontaneously 4
To verbal stimuli 3
To pain 2
No response to pain 1
Best Motor Response  
Spontaneous or obeys verbal command 6
Localises to pain or withdraws to touch 5
Withdrawn from pain 4
Abnormal flexion to pain 3
Abnormal extension to pain 2
No response to pain 1
Best Verbal Response  
Alert, babbles, coos, words to usual ability 5
Less than usual words, spontaneous irritable cry
4
Less than usual words spontaneous cry 3
Moans to pain 2
No response to pain 1


2.    Observe the child’s
posture

·         Floppy
(hypotonic) – if new onset,
assume child is seriously ill until proven otherwise

·         Stiff
(hypertonic
) or back arching –
if new onset, regard as a sign of cerebral upset
·         Decerebrate or
decorticate posturing
– indicates serious cerebral abnormality


3.   
Assess the
pupils

·        
Pupils should be
equal, normal size and react briskly to light

4.    Measure the blood
glucose levelAny child presenting
with significant difficulties involving:

·         Airway

·         Breathing

·         Circulation

·         Disability


Must be
treated as time Critical


Ongoing
Assessment
Use
structure of initial assessment for any ongoing assessments


CUPS Method
of classifying Sick Children

Critical Absent airway,
breathing or circulation
(cardiac or
respiratory arrest or severe traumatic injury)
Unstable Compromised airway,
breathing or circulation
(Unresponsive,
respiratory distress, active bleeding, shock, active seizure, significant
injury, shock, near-drowning, etc.)
Potentially
Unstable
Normal airway,
breathing & circulation but significant mechanism of injury or
illness
(Post-seizure, minor
fractures, infant < 3mo with fever, etc.)
Stable Normal airway,
breathing & circulation
No significant
mechanism of injury or illness
(small lacerations
or abrasions, infant ≥ 3mo with
fever)


Specific Conditions in Children
Febrile
Convulsions
A febrile
convulsion, also known as a fever fit or febrile
seizure, is a convulsion associated with a significant rise in body
temperature. They most commonly occur in children between the ages of 6 months
to 6 years and are twice as common in boys as in girlsThe child is unable
to regulate its own body temperature due to an immature hypothalamus. As body
temperature rises rapidly during an episode of infection, usually >39°C most
children will experience a brief full body seizure that is tonic-clonic in
nature usually lasting 1-2 minutes. But can last up to 15minutes, a simple
febrile
convulsion should not reoccur with 24 hours. However a complex febrile
convulsion can occur and is characterized by
longer duration, recurrence, or focus on only part of the body.34% of all children
between the ages of 3 months and 5 years will have a febrile convulsion and 1:3
risk further convulsions. There is evidence that indicates a higher risk of
further seizures if the first seizure occurs before the age of 1 year. However,
only 1% of children will go on to develop epilepsy.


Croup
This is a breathing
problem most commonly seen in children between 6 months and 5–6 years of age
that is caused by an infection of the upper airway causing swelling inside the
throat which in turn causes the classic "barking" seal like cough. Other
symptoms are a grating upper airway sound (Stridor), hoarseness, difficulty in
breathing, fever, rhinitis, drooling and sternal recessions. Symptoms vary in
intensity and can be worse at night. Normally treated by GP but in rare cases
can be very serious.

Normal Stages
of
Human
Development
(Birth to 5 Years)

The flowing
information is derived from the Child Development Institute: Parenting Today
It is
important to keep in mind that the time frames presented are averages and some
children may achieve various developmental milestones earlier or later than the
average but still be within the normal range.  


Birth to 1 month
Feeds: 5-8 per day,
Sleep: 20 hrs per day
Sensory Capacities: makes basic distinctions in vision,
hearing, smelling, tasting, touch, temperature, and perception of
pain.Emotional:
Generalized TensionSocial: Helpless,
Asocial, Fed by mother


2  to 3 months
Sensory Capacities: 
colour perception, visual exploration, and oral exploration.
Sounds: cries,
coos, grunts
Motor Ability: control of eye muscles, lifts head when on
stomach.Emotional: Delight,
Distress, Smiles at a FaceSocial: Visually
fixates at a face, smiles at a face, may be soothed by
rocking.


4 to 6 months
Sensory Capacities: 
localizes sounds
Sounds:  babbling makes most vowels and about half of the
consonants
Feedings: 3-5 per day

Motor Ability:  control of head and
arm movements, purposive grasping, rolls over.Emotional: Enjoys
being cuddledSocial: Recognizes
his mother.  Infant distinguishes between familiar persons and strangers, no
longer smiles indiscriminately.  Expects feeding, dressing, and
bathing.


7 to 9
months
Motor Ability: 
control of trunk and hands, sits without support, crawls about.Emotional: Specific
emotional attachment to mother, protests separation from mother.Enjoys games such as
"peek-a-boo"


10  to 12 months
Motor Ability: 
control of legs and feet, stands, creeps, apposition of thumb and
fore-finger.
Language:  says one or two words, imitates sounds, and responds
to simple commands.
Feedings:  3 meals, 2 snacks. Sleep:  12 hours, 2
napsEmotional: Anger,
Affection, Fear of strangers, Curiosity, explorationSocial: Responsive
to own name.  Wave bye-bye.  Plays pat-a-cake, understands "no-no!"  Gives and
takes objects.


1 to 1 ½
years

Motor Ability:  creeps up stairs, walks (10-20 min), and makes
lines on paper with crayon.
Emotional: Dependent
Behaviour, Very upset when separated from mother, Fear of BathSocial: Obeys
limited commands, repeats a few words, Interested in his mirror image, feeds
himself.


1 ½ to 2 years
Motor Ability: 
runs, kicks a ball, and builds 6 cube tower (2yrs) Capable of bowel and bladder
control.
Language:  vocabulary of more than 200 words. Sleep: 12 hours at
night, 1-2 hr napEmotional: Temper
tantrums (1-3yrs), Resentment of new baby.
Social: Does
opposite of what he is told (18 months).

2 to 3 years

Motor Ability: jumps off a step, rides a tricycle, uses crayons,
builds a 9-10 cube tower.
Language: starts to use short sentences controls
and explores world with language,   stuttering may appear
briefly.
Emotional: Fear of
separation, Negativistic (2 ½ yrs), Violent emotions, anger, Differentiates
facial expressions of anger, sorrow, and joy. Sense of humour (Plays
tricks)Social: Talks, uses
"I" "me" you" Copies parents' actions. Dependent, clinging, possessive about
toys, enjoys playing alongside another child, negativism (2 ½ yrs), resists
parental demands, gives orders.


3 to 4
years

Motor Ability:  Stands on one leg, jumps up and down, draws a
circle and a cross (4 yrs) Self-sufficient in many routines of home
life.
Emotional:
Affectionate toward parents, Pleasure in genital manipulation, Romantic
attachment to parent of opposite sex (3 to 5 yrs), Jealousy of same-sex parent.
Imaginary fears of dark, injury, etc. (3 to 5 years).Social: Likes to
share, uses "we" Cooperative play with other children, nursery school.  Imitates
parents.   Beginning of identification with same-sex parent, practices sex-role
activities.  Intense curiosity & interest in other children's bodies. 
Imaginary friend.


4 to 5 years
Motor ability: 
mature motor control, skips, broad jumps, dresses himself, copies a square and a
triangle.
Language: talks clearly, uses adult speech sounds, has mastered
basic grammar.Emotional:
Responsibility and guild, Feels pride in accomplishment
Social:  Prefers to play with other children, becomes
competitive prefers sex-appropriate activities.

Baby
check
Information adapted
from http://www.nicutools.org/MediCalcs/BabyCheck.php3
Baby Check can help
you assess the severity of illness in babies in the first six months of life and
measure improvement or worsening of condition.It’s not a
substitute for clinical judgment or common sense and assesses signs and symptoms
of generalized illness. Some conditions, such as injury, a convulsion or an
abscess, where the baby is not systemically ill, may get a low score but still
need medical assessment or treatment

 

Signs and Symptoms


Score


1


Unusual cry


E. g. high itched, weak, moaning or painful


2


2


Fluids taken in previous


24 hours


Less than normal


2


Half normal


4


Very little


9


3


Vomiting


Vomiting at least half of feed in the three previous
feeds


4


4


Vomiting bile


Any green bile vomit


13


5


Wet nappies (urine output)


Less urine than normal


3


6


Blood in nappy


Large amount of blood in nappy


11


7


Drowsiness


Occasionally drowsy


3


Drowsy most of the time


5


8


Floppiness


Baby seems more floppy than usual


4


9


Watching


Baby less watchful than normal


2


10


Awareness


Baby responding less than normally to the
surroundings


2


11


Breathing Difficulties


Minimal recession visible


4


Obvious recession visible


15

Normal
Respiratory rate 25-35  > 40 =
tachyponea
 

12


Looking Pale


Baby more pale than normal or has been pale in last 24
hours


3


13


Wheezing


Baby has wheezy breathing sounds


2


14


Blue Nails


Apparent blue nails


3


15


Circulation


Baby’s toes are white, or stay white for 3 seconds after
squeezing


3

Normal heart rate
110 – 150bpm >160 = tachycardia

3


16


Rash


Rash over body, or raw weeping area > 5 x 5
cms


4


17


Hernia


Obvious bulge in scrotum or groin


13


18


Temperature


Greater than 38.3 c (tempadot)


4


19


Crying during checks


Baby has cried during checks ( more than a
grizzle)


4

 

Total scores

 


0-7


Baby is only a little unwell, medical attention in not
necessary


8-12


Baby is not seriously unwell; parents would be advised to seek
advice from a health professional


13-19


Baby is ill, parents would be advised to contact a
doctor


>20


Baby is seriously ill, parents would be advised to seek immediate
medical attention



















Paediatric Trauma
Score
(PTS)

  +2 +1 -1
Weight >20 Kg (44lbs) 10-20 Kg(22-44lbs) <10
Kg(22
lbs)
Airway Patent Maintainable Non maintainable
Systolic BP >90 Radial 50-90 Carotid <50Non
palpable
CNS Awake Responsive Unresponsive
Fracture None Closed or ? Multiple or open
Wounds None Minor Major,
Penetrating or
>10% Burns

9-12 Minor Trauma
6-8 Potentially Life Threatening
0-5 Life Threatening
<0 Usually
Fatal

Assessing the
Elderly patient
A person becomes
elderly at the age of 65 however as this is based on retirement age, in
countries such as India this becomes irrelevant and a person is considered an
Elder or Elderly at around 50. At 85 a person is termed the oldest old. The
current average life expectancy for males is 77.4 years and 81.6 years for women
also the number of people living to 100 years in the UK has tripled since 1985
reaching 11,600 in 2009. Whatever term is used it is an inevitable part of aging
that the body will start deteriorating and eventually fail leading towards
death.Each body system
changes as we get older;


The
Respiratory
System (Lungs and
Airways)
The airways contain
cilia that are tiny hairs that move backwards and forwards and push dust and
foreign bodies out towards the nose or down the throat, but in the elderly
patient this movement is decreased so choking may occur. 
As people age the
number of alveoli where gaseous exchange of oxygen and carbon dioxide between
inspired air and the blood decrease. The lungs lose their elasticity and lung
volume is decreased. Changes in the density of bones often cause curvature of
the spine called kyphosis and weakening of the muscles of the diaphragm and
between the ribs decrease the maximum amount of air that is breathed in and
outAs
less air is breathed out this leaves some in the lungs which hampers gaseous
exchange and increases the amount of carbon dioxide in the blood. Cells in the
body called Chemoreceptor’s control the amount of oxygen in the blood these
become less sensitive in an elderly patient hence an oxygen saturation reading
of 93% to 95% may be normal. In a younger person a level of 96%+ is considered
normal. Chronic obstructive heart disease (COPD) can be caused by smoking or
underlying lung diseases, it usually affect patient from 35 years of age and
death usually occurs 10 years after onset of breathlessness.


The Cardiovascular
System (Heart and Blood Vessels)
A build up of fatty
deposits (atherosclerosis) in the blood vessels together with the loss of
elasticity will make the vessels more rigid which increases systolic blood
pressure.  As cardiac function declines with age, there is a
decrease in blood volume, pulse and the amount of blood pumped with each
heartbeat (stroke volume). There are natural
sensors in the blood vessels called baroreceptors these measure the pressure of
blood in the vessels and send signals to the brain when the body needs to adjust
the pressure when moving. In the elderly these become less sensitive so systolic
blood pressure can suddenly drop when moving from a sitting to a standing
position this can cause fainting, but a drop of less than 20 mmHg could be
normal for the patient. As part of the aging process the number of cells that
control the electrical signals in the heart decrease by up to 90% by the age of
75, there is also a loss of the fibres that channel electrical impulses through
the heart. This causes irregular heart rhythms (Arrhythmias) such as atrial
fibrillation (AF). Coronary heart disease is a failure of the hearts circulation
to supply adequate oxygen to the cardiac muscle and surrounding tissue a failure
of this system leads to heart attacks and angina.


Nervous
System
The weight of the
brain shrinks 10 to 20% by 80 years of age and losses between 5 to 50% of brain
cells (neurons) more in patients with dementia. The junctions between neurons,
motor and sensory networks become slower and less responsive. The shrinking brain
stretches the blood vessels from its surface to the inside of the skull this can
lead to haemorrhage. Nerves in the skin deteriorate which results in less pain
being felt from injuries.


Skin
The skin becomes
thinner, more wrinkled, drier, loses elasticity and become more fragile as we
age. Fat layers below the skin becomes thinner and outer skin
loosensIn older skin
uncontrolled bleeding produces large bruises (Haematoma) underneath the
skin.


TemperatureIn the elderly the
core body temperature drops, so a temperature of between 35–36 degrees C may
be normal and explains why older people feel colder. It also means that an older
person with a temperature of 37.1 C has a more virulent infection than a younger
person due to the difference in normal core
temperatures.


Kidneys, Liver and
Digestive system
Kidneys reduce in
size and there ability to filter the blood can reduce by up to 50% by the age of
90. The liver shrinks and its blood flow decreases. Changes in the stomach and
intestines reduce nutritional intake and metabolism. Taste bud sensitivity and
the production of saliva declines as well as gastric acid. Older people develop
a degree of glucose intolerance which can lead to diabetes and is often
overlooked until it becomes a more serious problem it can be diagnosed by taking
a blood sample after fasting overnight, a raised blood sugar is an indication of
diabetes.


Musculoskeletal
Muscle fibres become
smaller and fewer, ligaments and cartilage of the joints lose their elasticity,
muscle mass decreases and is replaced by fat and bone density reduces.
Osteoporosis is common in the elderly affecting around 50% of women and
20% of men, the bones fracture more easily, falls can result in fractured hips
which have a high related death rate of 30% within a year following the
fracture.


Cancer
Cancer cells in the body grow and reproduce in an uncontrollable
way.  It can spread to other areas of the body and this is called
metastasis. The damaged cells invade nearby healthy cells and destroy them
hastening the process. With the benefit of modern medicines, radiotherapy and
chemotherapy cancers are often curable without these the death rate is high. One
in three people will have some form of cancer during their lives, half of these
occur in the over 55s .