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38 Cards in this Set

  • Front
  • Back
Mortality rates
a. Infant mortality rate
b. Top causes of death worldwide in neonates (1-27 days)
c. Top causes of death worldwide in children aged 1-59 months
a. Infant mortality rate
I. The number of deaths of children under 1 year of age in one calender year per 1 000 live births in the same calender year.
(The highest death rate occur in the first 28 days, and the most deaths occur on the first day of life, male children are more likely to die than females in all age groups)

b. Top causes of death worldwide in neonates (1-27 days)
1. Preterm birth complications (12%)
2. Birth asphyxia (9%)
3. Sepsis (6%)
4. Pneumonia (4%)
5. Congenital abnormalities (3%)
(Complex congenital heart disease, CNS malformations, metabolic disorders, chromosomal anomalies)

(Diarrhea and tetanus each 1%)

c. Top causes of death worldwide in children aged 1-59 months
1. Diarrhea (14%)\Pneumonia (14%)
2. Other infections (9%)
3. Malaria (8%)
4. Injury (3%)
(AIDS and pertussis each 2%)

(Pertussis - acute infectious inflammation of the larynx, trachea and bronchi caused by Bordatella pertussis, characteristics spasmodic coughing)

(In developing countries, seven out of 10 childhood deaths can be attributed to just five main causes - pneumonia, diarrhea, measles, malaria, and malnutrition)

(APLS)
Main causes of cardiac arrest in children
Cardiac arrest in children
a. Respiratory failure
1. Respiratory obstruction
I. Foreign body
II. Asthma
III. Croup
(Acute obstruction of upper airways in infants and children characterized by a barking cough with difficult and noisy respiration)

2. Respiratory depression
I. Convulsions
II. Poisoning
III. Raised ICP
(<- Head injury, encephalopathy)

b. Circulatory failure
1. Fluid loss
I. Blood loss
II. Burns
III. Vomiting
(<- Gastroenteritis)
IV. Trauma

2. Fluid maldistribution
I. Sepsis
II. Anaphylaxis
III. Cardiac failure

(APLS)
Weight
a. Weight - Birth weight, at 1 year
b. Broselow or Sandell tapes
c. Weight formulas
a. Weight
I. Birth weight - 3.5 kg
II. At 1 year - 10 kg

b. Broselow or Sandell tapes
I. Use length of the child to estimate weight

c. Weight formulas
1. 0-12 months
I. Weight (kg) = (0.5 x age in months) + 4

2. 1-5 years
I. Weight (kg) = (2 x age in years) +8

3. 6-12 years
I. Weight (kg) = (3 x age in years) + 7

(APLS)
Anatomical differences in children
a. Differences in the airways of young children
b. When are children obligate nasal breathers
c. Why is it easier to intubate an infant with a straight-blade laryngoscope
d. Trachea - important differences
a. Differences in the airways of young children
1. Large head and small neck -> Neck flexion and airway narrowing

2. Loose teeth\orthodontic structures

3. Large tongue
(Obstruct airway in unconscious
child, impede view at laryngoscopy)

3. Horseshoe-shaped epiglottis
(Projects posteriorly 45 degrees)

4. High anterior larynx
(C2\3 as opposed to C5\6 in adults)

b. < 6 months
(Leave them at particular risk of airway compromise since the nasal passages are easily obstructed by mucous secretions and upper respiratory tract infections are common in this group)

c. The fact that larynx is high and anterior (C2\C3) and the shape (horseshoe) and posterior angle (45)

d. Trachea
I. Shorter and softer -> tracheal compression from hyperflexion or hyperextension
II. The structure of the carina makes a foreign object just as likely to enter the left bronchus as the right

(APLS)
Respiratory differences
a. Respiratory surface area of an infant
b. Why are the lower airways more easily obstructed
c. Infants rely mainly on diaphragmatic breathing, why
d. Why are infants more susceptible for respiratory failure
a. < 3 m2
(Also only 10% of the number of small airways compared to adults)

b. Smaller radius -> ↑Resistance to flow, lower 'reserve'
(Halving the radius increase the resistance 16-fold since resistance to flow is inversely proportional to the fourth power of the airway radius)

c. The ribs lie more horizontal and thus contribute less to chest expansion

d. The muscles fatigue more easily as they have fewer type I fibers
(Type I fibers are the slow-twitch, highly oxidative, fatigue-resistant type)

(APLS)
Anatomical differences in children
a. Cardiac ventricles
b. Body surface area
a. Cardiac ventricles
I. The two ventricles are of similar weight at birth, at two months the left ventricle is twice as large
(These changes are reflected in the infant's ECG)

b. Body surface area
I. Inversely proportional with age
II. At birth the head accounts for 19% of body surface area
(Small children with a high ratio lose heat more rapidly and are thus more prone to hypothermia)

(APLS)
Physiological differences in children
a. Metabolical
b. Respiratory
c. Immune function
a. Metabolical - Greater relative metabolic rate

b. Respiratory
I. Greater relative oxygen consumption reflected in increased respiratory rate
II. Most of the compliance is due to the lung, not the chest wall
(In adults its about 50-50)
III. The increased compliance of the chest wall allows the intrathoracic pressure to be less "negative"
(-> Reduce small-airway patency)
(The tidal volume remains quite constant at 5-7 ml\kg and so does the work of breathing at about 1% of the metabolic rate)

c. Immune function
I. The immune system is immature -> Increased susceptibility to infections
II. Maternal antibodies provide some protection the first 6 months
III. Breastfeeding also provide some protection against respiratory and GI infections

(Infancy < 1 year, childhood - 1 year to puberty)

(APLS)
Respiratory rate by age at rest - Age
a. < 1 year
b. 1-2 years
c. 2-5 years
d. 5-12 years
e. > 12 years
a. < 1 year - 30-40\min

b. 1-2 years - 25-35\min

c. 2-5 years - 25-30\min

d. 5-12 years - 20-25\min

e. > 12 years - 15-20\min

(The maximum rate decrease by 5 per age bracket and the 2 first have 10 range while the last has five)

(APLS)
Heart rate by age
a. < 1 year
b. 1-2 year
c. 2-5 year
d. 5-12 year
e. >12 year
a. < 1 year
I. 110-160\min

b. 1-2 year
I. 100-150

c. 2-5 year
I. 95-140

d. 5-12 year
I. 80-120\min

e. > 12 year
I. 60-100\min

(The first 3 age brackets have 50 in range (almost), begin at 160 max and the max decrease by 10 per age bracket, > 12 is normal)

(APLS)
Cardiovascular differences
a. Stroke volume of an infant
b. Cardiac index (ml\min\kg) at birth, puberty, adulthood
a. 1.5 ml\kg
(-> The response to volume therapy is blunted because stroke volume cannot increase greatly to improve cardiac output, similar to adults at 2 years of age. CO is determined mainly by heart rate)

b. Cardiac index
I. Infancy - 300 ml\min\kg
II. Puberty - 100 ml\min\kg
III. Adulthood - 70-80 ml\min\kg

(Infancy < 1 year, childhood 1 year to puberty)

(APLS)
Systolic blood pressure by age
a. Equation for expected systolic blood pressure for the 50th percentile
b. Equation for expected systolic blood pressure for the lower 5th percentile
a. Equation for expected systolic blood pressure for the 50th percentile
BP = 85 + (age x 2)
(For the 50th percentile in height, 8-9 mmHg differences between 5th and 95th percentile at any age for boys, 6-7 mmHg --||-- girls)

b. Equation for expected systolic blood pressure in the lower 5th percentile
BP = 65 + (age x 2)

(APLS)
The initial approach
a. Components
b. If there is only one rescuer he should start CPR and call for EMS if no help has arrived after 1 minute. Under which circumstances should EMS be called before CPR is begun in the case of a single rescuer
a. 3S
1. Safety - Free from danger
2. Stimulate - Are you alright? Hold head and shake arm
(Hold head to avoid exacerbating a possible neck injury)
3. Shout for help

b. Clinical indications for EMS activation before BLS by a lone rescuer
1. Witnessed sudden collapse with no apparent preceding morbidity
2. Witnessed sudden collapse in a child with a known cardiac condition and in the absence of a known or suspected respiratory or circulatory cause of arrest
(= Indicated when the cause is assumed to be cardiac and early defibrillation is critical)

(APLS)
Airway
a. How is the airway opened in an unconscious child where its assumed that the tongue has fallen back and obstructed the airway - Procedure in children and in infants
b. How is the airway kept open if the head tilt\chin lift manoeuvre is contraindicated because of suspected neck injury
c. How is the patency of the airway assessed
a. Chin lift\Head tilt
1. Children - Hand on forehead\vertex, fingers on chin. Tilt back to sniffing position
2. Infant - Hand on forehead\vertex, finger on chin. Tilt back to neutral position
(Let a child with partial airway blockage which is conscious find its own best position)

b. Jaw thrust manoeuvre
1. Place 2-3 fingers under the angle of the mandible bilaterally
2. Lift the jaw upward
(Lift tongue away from pharynx, easier if the rescuer's elbows are resting on the same surface as the child is lying on)

c. Patency of the airway - Use 10s
1. Looking - For chest and\or abdominal movement
2. Listening - For breath sounds
3. Feeling - For breath
(Place face above the child's with the ear over the nose, the cheek over the mouth, and the eyes looking along the line of the chest)

(APLS)
Breathing
a. If normal breathing starts after the airway is opened ......
b. If head tilt\chin lift or jaw thrust don't result in the resumption of adequate breathing within 10 seconds ....
c. Causes of chest not rising on rescue breaths
a.
I.-> Recovery position
II. Continue to monitor child for normal breathing
(Must distinguish from ineffective, gasping or obstructed breathing)
III. Send or go for help

b. Give five initial rescue breaths
I. Mouth-to-mouth for children
(Close nose)
II. Mouth-to-mouth-and-nose for infants
(The rescuer should take a breath between rescue breaths to maximise oxygenation of the victim, the chest should be seen to rise, inflation pressure may be higher because the airway is small, slow breaths at the lowest pressure reduce gastric distension. Firm, gentle pressure on the cricoid cartilage may reduce gastric insufflation)

c. Causes of chest not rising on rescue breaths
1. Failure to apply correctly the airway-opening techniques
(-> Readjust head tilt, try jaw thrust)
2. Foreign body obstruction

(APLS)
Circulation
a. Indications for chest compressions\Signs of circulatory failure
b. Signs of poor perfusion
a. Signs of circulatory failure
1. Absence of signs of life
I. Movement
II. Coughing
(In response to rescue breaths)
III. Normal breathing
(Not agonal breaths (irregular, infrequent))

2. Absence of central pulse for up to 10 seconds or presence of bradycardic (<60) pulse
I. Child - Carotid, femoral
II. Infant - Brachial, femoral
(Carotid is covered with fat in infant, feel for brachial artery in the medial aspect of the antecubital fossa)

b. Signs of poor perfusion
1. Pallor
2. Lack of responsiveness
3. Poor muscle tone

(APLS)
Chest compressions
a. Position for infants
b. Depth
c. Rate of compression
d. Ratio with rescue breaths
e. Differences for children
a. Position for infants
1. Hand-encircling technique
I. The infant is held with both the rescuer's hands encircling or partially encircling the chest
II. The thumbs are placed over the lower half of the sternum and compressions are carried out
(Only possible when there are two rescuers, preferred method then)

2. Two-finger method
I. Compress lower sternum with two fingers
II. Maintain head position\airway with the other hand

b. Depth - At least 1\3 of the infant's chest
(Same for children)

c. 100-120\min

d. 15-2

e. Differences for children (>1 year to puberty)
I. compression position for adults are used
II. Depth is still at least 1\3 of chest,
III. Rate and ratio is the same
(Ratio is changed to 30-2 after puberty to reflect the change of primary etiology from respiratory to cardiac)

(APLS)
(APLS)
Foreign body airway obstruction (FBAO)
a. Requirements
b. Blanks
a. Requirements
I. The diagnosis of FBAO is clear cut - Witnessed or strongly suspected
II. Ineffective coughing and increasing dyspnea, LOC,or apnea have occurred

(An effective cough is recognized by the victim's ability to speak or cry and to take a breath between coughs)

(APLS)
Foreign airway obstruction (FBAO)
a. Typical sequence and S&S
b. In which conditions can manipulations of foreign body make the matter worse, and immediate transport to the hospital should be prioritized
a. Sudden onset of respiratory compromise, associated with coughing, gagging and stridor.

b. Infectious causes - acute epiglottitis, croup

(APLS)
Foreign airway obstruction - Infants
a. How are back blows performed
b. How are chest thrusts performed
a. Back blows
1. The infant is placed along one of the rescuer's arms in a head down position
(The rescuer supports the head in the neutral position for airway patency)

2. The rescuer then rests his or her arm along the thigh, and delivers five back blows with the heel of the hand

b. Chest thrusts
1. The baby is turned over, still in a head-down position

2. Five chest thrusts are given, using the same landmarks as for CPR but at a rate of one per second
(Abdominal thrusts is not used because they may cause intra-abdominal injury)

(APLS)
Foreign airway obstruction - Infants
a. How are back blows performed
b. How are chest thrusts performed
a. Back blows
1. The infant is placed along one of the rescuer's arms in a head down position
(The rescuer supports the head in the neutral position for airway patency)

2. The rescuer then rests his or her arm along the thigh, and delivers five back blows with the heel of the hand

b. Chest thrusts
1. The baby is turned over, still in a head-down position

2. Five chest thrusts are given, using the same landmarks as for CPR but at a rate of one per second
(Abdominal thrusts is not used because they may cause intra-abdominal injury in infants)

(APLS)
Foreign airway obstruction (FBAO) in children
a. Procedure for back blows
b. Procedure for abdominal thrusts
a. Back blows
I. As in infants for small children
II. In the case of a larger child, support him in a forward leaning position

b. Abdominal thrusts\Heimlich maneuver
1. Standing
I. Might need to lift child or stand or kneel
II. One hand is formed into a fist and the other hand is placed over the first
III. The hands are placed against the child's abdomen between the umbilicus and xiphoid process
III. Repeated five times

2. Lying down\supine
I. Similar
II. The heel of hone hand is placed against the child's abdomen between the umbilicus and xiphoid process
III. The other hand is placed on top of the first, and both hands are thrust sharply upwards into the abdomen five times
(Care should be taken to direct the thrust in the midline)

(APLS)
Laryngoscopy for children
a. Straight blade - Mechanism, Pros, cons
b. Curved blade - Mechanism, Pros, cons
a. Straight blade laryngoscope
I. Directly lift epiglottis
II. Good mobility of epiglottis, easier to elicit vagal stimulation causing laryngospasm or bradycardia

b. Curved blade laryngoscope
I. Move epiglottis by putting pressure on the vallecula thus pulling epiglottis open
II. Less chance of vagal stimulation
(Maybe equally effective)

(APLS)
Tracheal tubes
a. Difference in anatomy of larynx in children < 10 years
b. Practical test to see if tube is of right size
c. Children > .... can use cuffed tubes
d. Estimation of appropriate size of uncuffed tracheal tube for children between 1-10 years
e. Estimation of internal diameter of cuffed tube for children > 2 years
a. The narrowest point is at the cricoid ring, rather than the vocal cords as in adults

b. An appropriately sized tube should give a relatively gas-tight fit in the larynx but should not be so tight that no leak is audible when the bag is compressed.
(Failure to observe this condition may lead to damage to the mucosa at the level of the cricoid ring and to subsequent edema following extubation)

c. 1 year
(Uncuffed tubes should be used during resuscitation by those who do not have much pediatric anesthetic experience)

d.
I. Internal diameter (mm) = (Age\4) + 4
II. Length for oral tube (cm) = (Age\2) + 12
III. Length for nasal tube (cm) = (Age\2) + 15
(Neonates usually require a tube of internal diameter 3-3.5 mm, smaller in preterms)

e. Internal diameter (mm) = (Age\4) + 3.5
(For infants > 3kg and up to one year, a size 3 cuffed tube and from 1-2 years a size 3.5 cuffed tube are usually acceptable)

(APLS)
Respiration
a. Primary assessment of airway and breathing
b. Secondary assessment of airway and breathing
a. Assessment of airway and breathing
1. Look, listen and feel for airway obstruction, respiratory arrest, depression or distress
2. Assess the effort of breathing
3. Count the respiratory rate
4. Listen for stridor and\or wheeze
5. Auscultate breath sounds
6. Assess skin color

b. Secondary assessment of airway and breathing
1. Perform a detailed examination of the airway, neck and chest
2. Identify any swelling, bruising or wounds
3. Re-examine for symmetry of breath sounds and movement
(Don't forget to inspect and listen to back of chest)

(APLS)
Airway (A) protocol - First assess airway and give oxygen, then
a. If evidence of blunt trauma
b. If evidence of obstruction or altered consciousness
c. If obstruction persists
d. If obstruction still persists
e. If intubation is impossible or unsuccessful
f. If stridor but relatively alert
a. If evidence of blunt trauma
I. Protect cervical spine from the outset

b. If evidence of obstruction or altered consciousness
I. Perform airway-opening maneuver
II. Consider suction and foreign body removal

c. If obstruction persists
I. Consider oro- or nasopharyngeal airway or LMA

d. If obstruction still persists
I. Consider intubation

e. If intubation is impossible or unsuccessful
I. Consider cricothyroidotomy

f. If stridor but relatively alert
I. Allow self-ventilation whenever possible
II. Encourage oxygen but do not force to wear mask
III. Do not force to lie down
IV. Do not inspect airway (except as a definite procedure under controlled conditions)
V. Assemble expert team and equipment

(APLS)
Breathing (B) protocol
a. If respiratory arrest or depression
b. If sedative or paralysing drugs is possible
c. If lateralised ventilatory defect
d. If chest injury
e. If evidence of tension pneumothorax
f. If evidence of massive hemothorax
g. If wheezes or crackles
h. If evidence of acute severe asthma
a. If respiratory arrest or depression
I. Administer oxygen by bag-valve-mask
II. Consider intubation

b. If sedative or paralysing drugs is possible
I. Administer reversal agent if respiratory distress or tachypnea
II. Administer oxygen

c. If lateralised ventilatory defect
I. Consider hemopneumothorax, inhaled foreign body, lung consolidation, collapse, or effusion

d. If chest injury
I. Consider tension pneumothorax and massive hemothorax, flail segment, or open pneumothorax

e. If evidence of tension pneumothorax
I. Perform immediate needle decompression, follow up with chest drain

f. If evidence of massive hemothorax
I. Insert chest drain
II. Commence blood volume replacement

g. If wheezes or crackles
I. Consider asthma, bronchiolitis, pneumonia, heart failure, inhaled foreign body

h. If evidence of acute severe asthma
I. Give inhaled or intravenous beta-agonist
II. Give steroids
III. Consider aminophylline
(Solubilized form of theophylline, diuretic, vasodilator, bronchodilator, and cardiac stimulant)

(APLS)
Cardiac arrest
a. What is the most common arrest rhythm in children
b. Causes
a. Asystole is the most common arrest rhythm in children
(The response of the young heart to prolonged severe hypoxia and acidosis is progressive bradycardia leading to asystole)

b. Cardiac arrest - Causes
4Hs
1. Hypoxia
(Prime cause of cardiac arrest in childhood)

2. Hypovolemia
(May be significant in arrests associated with trauma, anaphylaxis, and sepsis, and requires infusion of crystalloid)

3. Hyperkalemia\Electrolyte abnormalities
I. Hypokalemia
II. Hypocalcemia
(IV calcium gluconate is indicated in hyperkalemia, hypocalcemia, and calcium channel blocker overdose)

4. Hypothermia - Drownings

4Ts
5. Tension pneumothorax,

6. (Cardiac) Tamponade
(5-6 are especially associated with PEA and found in trauma cases)

7. Toxins

8. Thromboembolic phenomena
(Much less common in children)

(APLS)
Cardiac arrest
a. Evidence for use of adrenaline cardiac arrest
b. Calcium - Use in cardiac arrest
c. Alkalizing agents (Bicarbonate) - Use in cardiac arrest
d. Sodium bicarbonate - Precautions with administration
a. Evidence for use of adrenaline in cardiac arrest
I. Prospective randomized study in adults showed an improvement in ROSC but no increase in long-term neurologically intact survival
II. Shown in animal studies to improve relative coronary and cerebral perfusion

b. Calcium - Use in cardiac arrest
I. Not used routinely because there is no evidence for its efficacy and there is evidence of harmful effects
(Ca is implicated in cytoplasmic calcium accumulation in the final common pathway of cell death)
II. Used for documented hyperkalemia, hypocalcemia, hypomagnesemia, and calcium-channel blocker overdose

c. Sodium Bicarbonate - Cardiac arrest
1. Prolonged cardiac arrest where profound acidosis is likely to adversely affect the action of adrenaline
(Bicarbonate is converted to CO2 and ventilation must therefore be secured before administration)
2. Hyperkalemia
3. Antidepressant overdose

d. Sodium bicarbonate - Precautions with administration
1. Bicarbonate must not be given in the same IV as calcium because precipitation will occur

2. It inactivates adrenaline and dopamine and therefore the line must be flushed with saline if these drugs are subsequently given

3. Bicarbonate must not be given intra-tracheally

(APLS)
Cardiac arrest
a. VF\pVT - Common causes in children
b. Pediatric paddles (4.5 cm) - Indications for use, placement
a. VF\VT - Common causes in children
1. Congenital heart disease
2. Hypothermia
3. Some drug overdoses - TCAs
(A sudden witnessed collapse is very suggestive for VF\pVT)
(pVT - pulseless VT)

b. Pediatric paddles
I. Use in children < 10 kg
II. One over the apex in the midaxillary line, the other immediately below the clavicle to the right of the sternum
III. If the paddles are too large, one is placed on the upper back below the left scapula, and the other on the front to the left of the sternum
Cardiac arrest
a. Amiodarone - Indications, dose
b. Second choice if amiodarone is not present
c. Magnesium - Indications
d. The order of decreasing preference for defibrillation in those < 1 year is
a. Amiodarone
I. Shock resistant VF\pVT
II. 5 mg\kg via rapid IV
(Less helpful with hypothermia and VF\pVT from overdose of arrhythmogenic drugs)

b. Lidocaine
(1 mg\kg IV)
(The purpose of the antiarrhythmic drug is to stabilize the converted rhythm)

c. Magnesium
I. Hypomagnesemia
II. Polymorphic VT\Torsade de pointes ('Twisting of the points')

d. The order of decreasing preference for defibrillation in those < 1 year
1. Manual defibrillator
2. AED with dose attenuator
(Pediatric attenuation pads which decrease the energy to a level more appropriate for the child or leads reducing the total energy to 50-80 joules)
3. AED without dose attenuator

(APLS)
Primary assessment of airway and breathing
a. Signs of increased breathing effort
b. In which 3 circumstances can there be absent or decreased evidence of increased effort of breathing
a. Signs for increased breathing effort
1. Respiratory rate
I. WHO use 60 breaths\min as a cut-off for pneumonia in infants and young children
(Infants can show rates of between 30-90 bpm depending on their state of activity)
II. At rest, tachypnea indicates that increased ventilation is needed because of either lung or airway disease, or metabolic acidosis
III. A slow respiratory rate indicates fatigue, cerebral depression, or a pre-terminal state

2. Recession - Intercostal, subcostal, sternal, suprasternal (tracheal tug)
I. Its presence in older children (> 6) suggests severe respiratory problems

3. Respiratory noises
I. Inspiratory stridor - Laryngeal or tracheal obstruction
(Can be present in expiration too, but usually more pronounced in inspiration)
II. Expiratory wheezing - Lower airway narrowing

4. Grunting
I. Exhalation against a partially closed glottis
II. Attempt to generate a positive end-expiratory pressure and prevent airway collapse at the end of expiration in children with "stiff" lungs (pneumonia, pulmonary edema, abdominal distention, peritonism)
(Also seen in ↑ICP)

4. Accessory muscle use - SCM
I. Ineffectual in children

5. Flaring of the nostrils
I. Seen especially in infants

6. Gasping
I. Sign of severe hypoxia
II. May be pre-terminal

b. In which 3 circumstances can there be absent or decreased evidence of increased effort of breathing
1. Exhaustion - In the child who has had severe respiratory problems for some time, pre-terminal sign

2. Children with cerebral depression
I. ↑ICP
II. Poisoning
III. Encephalopathy
(Caused by decreased respiratory drive)

3. Children with neuromuscular diseases
I. Spinal muscular atrophy
II. Muscular dystrophy

(APLS)
Effects of respiratory inadequacy on other organs
a. Heart rate
b. Skin color
c. Mental status
a. Heart rate
I. Hypoxia produce tachycardia in the older infant and child
(Non-specific, also caused by anxiety, a fever..)
II. Severe or prolonged hypoxia leads to bradycardia, this is a preterminal sign

b. Skin color
I. Hypoxia produce skin pallor via catecholamine-mediated vasoconstriction
II. Cyanosis is a late and pre-terminal sign of hypoxia, spO2 must usually be < 70%
(The patient is close to respiratory arrest when central cyanosis is visible)

c. Mental status
I. Agitated -> drowsy -> unconscious
(A generalized muscular hypotonia also accompanies hypoxic cerebral depression)

(APLS)
Circulation (C)
a. Ways to recognize potential circulatory failure
b. Features suggesting a cardiac cause of respiratory insufficiency
a. Ways to recognize potential circulatory failure
1. Tachy- or severe bradycardia

2. Low pulse volume
(Absent peripheral pulses and weak central pulses are serious signs of advanced shock)

3. Capillary refill > 2 seconds
(Helpful in early septic shock, when the child may otherwise appear well, with warm peripheries)
(Apply pressure for 5 seconds)
(Use nail beds or sole of feet in children with pigmented skin)

4. Hypotension
(BP = 85 + (Age x 2) for 50th percentile, BP = 65 + (Age x 2) for 5th percentile.)
(Hypotension (< the 5th percentile) is a late and pre-terminal sign of circulatory failure. Cardiac arrest is imminent)

5. Skin pallor & cold peripherally

6. Agitation -> Drowsiness -> Unconsciousness
(Characteristic of circulatory failure)

7. Urinary output
I. < 1 ml\kg\h in children
II. < 2 ml\kg\h in infants
(-> Oliguria? Anuria?)

b. Features suggesting a cardiac cause of respiratory inadequacy
1. Cyanosis not correcting with oxygen therapy
2. Tachycardia out of proportion to respiratory difficulty
3. ↑JVP, ↑Liver
4. Absent femoral\peripheral pulses

(APLS)
Disability (D)\Neurological
a. Rapid way of assessing conscious level
b. Pupils - Most important to assess
c. Breathing pattern signs
d. Circulatory signs
a. AVPU - Respond to
I. Already Alert
II. Verbal stimuli
III. Painful stimuli - Responds only to pain
IV. Unresponsive to all stimuli
(Sternal pressure, supra-orbital ridge pressure. Note response (eyes, limbs, sounds)

b. Pupils
I. Dilated?
II. Reactive?
III. Equal?

c. Breathing patterns
I. Hyperventilation
II. Cheyne-Stokes
III. Apnea
(Abnormal respiratory pattern -> brainstem dysfunction)

d. Circulatory signs
I. Cushing's response
1. Hypertension
2. Bradycardia
3. Breathing irregularities
(Indicates compression of the medulla oblongata. Caused by herniation of the cerebellar tonsils through the foramen magnum. Late and preterminal sign)

(APLS)
Exposure (E) - What should one look for and what does it indicate
Exposure
1. Fever
I. Suggestive of infection
(Infection can present with low body temperature in infants)
II. Can be result of prolong convulsion or shivering

2. Rash and bruising
I. Allergic reaction - Urticaria, erythematous rash, maculopapular rash
(Maculopapule - Lesion with a flat base surrounding a central papule)
II. Septicemia - Petechiae, purpura, bruising

(APLS)
Primary assessment of child - Steps
Primary assessment
1. Airway and breathing
I. Effort of breathing
II. Respiratory rate and rhythm
III. Stridor\wheeze
IV. Auscultation
V. Skin color

2. Circulation
I. Heart rate
II. Pulse volume
III. Capillary refill
IV. Skin temperature

3. Disability
I. Mental status\conscious level
II. Posture
(Decerebrate\extensor, decorticate\flexor)
III. Pupils

4. Exposure
I. Fever
II. Rash and bruising

(APLS)
The respiratory system
a. Symptoms
b. Signs
c. Investigations
a. Symptoms
1. Breathlessness\Dyspnea
2. Coryza\Acute rhinitis
(Acute catarrhal (↑mucus & exudate) inflammation of the mucous membrane of the nose, usually associated with infection by one of the common cold viruses)
3. Cough
4. Noisy breathing - Grunting, stridor, wheeze
5. Drooling and inability to drink
6. Abdominal pain
7. Chest pain
8. Apnoea
9. Feeding difficulties
10. Hoarseness

b. Signs
1. Cyanosis
2. Tachypnea
3. Recession
4. Grunting
5. Stridor
6. Wheeze
7. Chest wall crepitus (crackling)

c. Investigations
1. Oxygen saturation
2. Peak flow if asthma is suspected
3. End-tidal\transcutaneous CO2 if hypoventilation is suspected
4. Blood culture if infection is suspected
5. Chest X-ray (selective)
6. Arterial blood gases (selective)

(APLS)
Efficacy of breathing - 3 things to pay attention to
Efficacy of breathing
1. Chest expansion - Volume, Symmetry

2. Air entry
I. Listen in all areas (front, back, axillae)
II. Listen for normal or reduced, bronchial or asymmetric breath sounds

3. sP02
I. >95% - Normal
II. 85-95% - Low, require oxygen
III. <85% - Seriously low, the child is in respiratory failure

(APLS)