Pediatrics, Caring Kids, Their Health - illness, Dr Kondekar Santosh - Pediatrician Mumbai
ASSESSMENT OF A SICK CHILD
Introduction
. Identifying the acutely ill child with a serious illness is accomplished by careful observation, history taking, physical examination, appreciation of age and body temperature and other parameters as risk factors and judicious use of screening laboratory tests.
History taking and observational assessment is to be continued as the physical examination is performed simultaneously. Observation is the key factor in evaluation of children with acute serious illness.
Accurate emergency assessment of the patient or a sick child presenting to emergency or casualty is the key in detecting the seventy of illness and risk to vitality of life and body systems.
In contrast to adult medicine, 60 to 70% of sick children presenting to emergency units will not have a serious or life threatening illness, but if overlooked 10-20% of the sick children presenting to emergency unit may have serious / acute illness which may be missed clinically2.
Therefore it needs careful evaluation of children presenting to emergency department to detect early the severity of disease.
Advances have been made in rapid investigations and therapeutic interventions in modern medicine, but history taking and general assessment of the sick child still forms the basics of diagnosis.
There can be no single tool which can replace clinical emergency assessment, newer devices can only assist the same.
Emergency assessment of sick child
As a patient presenting to emergency unit may present with any of the infinite number of possibilities of derangement of vital organs systems, the accuracy and speed in detecting life threatening and potential life threatening conditions through rapid clinical assessment assists physicians in making provisional diagnosis and treating the patient earliest with best possible interventions and therapies.
A representive assessment of each vital system or organs {viz: respiratory, cardiovascular, neurological system etc.} is important, to anticipate potential life threatening illnesses at least on a broader scale. As the child can present with any of the clinical presentations, sorting out critically ill children and children requiring intensive interventions needs to be done, in the emergency system, at the earliest possible time.
Methods of assessment of vital systems :
Depending on different presentations, different methods of clinical assessment are described :
1. Traditional methods of General and Systemic Special Examination
2. Acute illness observation scales12
3. Signs and symptoms specific scales
4. And specialised scales for different diseases:
· Clinical Asthma Score13
· Westley croup score11
· Glasgow Coma Score11
· Pain scales CRIES , CHEOPS scores12
· McCarthy Scale12
Limitations of modified clinical assessment scales :
1. Most of these scales are specailised for specific system derangement e.g. GCS, Asthma score, telling less about other systems.
2. Multisystem derangements can give false scores.
3. Many parameters, so may be cumbersome to remember and to calculate.
4. Can never replace complete clinical examination
Traditional Methods of Assessment of Sick child
Clinicians or best called as the diagnosticians in pediatric out patient care unit and pediatric emergency care unit need to know all possible life threatening conditions and such potential conditions in any sick child presenting to a emergency unit ..
Inferring from short and adequate but rapid clinical history and early and complete examination of different vital parameters and examining specifically for clinical signs / symptoms of potential life threatening illness, which help the pediatrician in sorting out relatively ‘stable’ cases from ‘sick children’ – who require early intervention and hospital based care or referral to a higher specially or intensive care unit. So a thorough general examination of child was advisable with respect to following parameters :
1. General Appearance - Normal / Sick / Very sick
2. Vital parameters
· Temperature
· Respiration
· Pulse
· Blood pressure
· Weight
3. Potential life threatening signs:
· Pallor
· Cyanosis / clubbing
· Edema
· Icterus
· High / Low JVP
· Capillary Refill time
· Bleeding tendencies
· Lethargy and altered sensorium etc.
General examination / appearance
Thus a sick child according to parents can be any child who is not normal / not behaving normal or has some abnormal symptom or sign – it can be any thing from fever, lethargy, excessive crying refusal to feeds to severe sepsis, bleeding tendencies, unresponsiveness. So a sick child although means need for therapeutic intervention, does not always mean a serious illness or a potential life threatening situation. The term very sick child although is more subjective, is usually associated with high chance of potential life threatening illness. It’s the pediatrician who on further examination decides regarding the need for early intervention and hospital based treatment2.
Vital Parameters
Normal functioning of different body functions depends on the state of vitality of different organs and systems. Thus there are vital organs namely heart, lungs, brain and accessory vital organs namely liver, kidneys, adrenals etc. Also there are vital systems – related to physiology of vital organs – namely cardiovascular system, respiratory system, nervous system and other systems like alimentary, excretory, reticuloendothelial system.
Age old knowledge of vital organs made to device few clinical parameters as representative parameters or representative vital parameters mainly –
Temperature,Pulse ,Respiration,Blood pressure…etc.
Also modern clinicians and pediatricians have deviced accessory vital parameters which are the potential life threatening signs as mentioned above.
Medical advances have developed in devicing novel methods to detect derangements in vital systems the earliest viz: Non invasive Blood Pressure measurement devices, Transcutaneus oximeters,expiratory air capnometers, and pulse oximeters. So, advances have been made to detect derangement of O2 and CO2 at intravascular / capillary / tissue level before it manifests clinically, by oximetry and capnometry. Capnography can provide early warning to potential life threatening problems, but such problems often result in desaturation. NIBP also is an important and reliable mode of assessing circulatory status but changes in blood pressure are seen very late, compared to other vital parameters.
Bedside monitoring of more complex variables is now feasible. However, it is important to remember that a monitored variable cannot replace and should be used in conjunction with careful and repeated physical examinations and bedside evaluation of patient14.
Some have suggested pain, weight, noninvasive blood pressure and smoking status of family members as an important vital parameter2.
Temperature :
Normal body temperature is maintained by exchanging heat at periphery mainly through skin through its arteriolar and various capillary network, with the air.
Thus assessment of temperature can help in assessing :
1. Basal Metabolic Rate.
2. Adequacy of circulation.
3. Temperature can be the only distinguishing marker for diagnosing – sepsis, pontine hemorrhages etc.
4. Comparative assessment of peripheral (axillary) and central (rectal temperatures) may help in early diagnosis of disease state.
Pulse :
The main vital parameter which makes the tissue and organs and also other vital organs ‘live’,by supplying them the adequate requirement of oxygen and energy to maintain health and fight illnesses. It’s a peripheral manifestation of cardiac activity. There are people and whole system of Ayurveda, who can diagnose different illnesses by just feeling for pulse. Apart from cardiac function, pulse also determines the peripheral resistance. The different parameters of pulse viz. Rate, Rhythm, Volume, Tension etc help in early detection of potential cardiovascular illnesses which other wise remain undetected.
Blood Pressure :
Another important parameter for assessment of cardiovascular system and the systemic circulation is blood pressure. It mainly estimates peripheral resistance and the cardiac output which are the two main things which get decompensated in severe illness. Not only hypertension, but hypotension is also equally significant marker of detecting early derangement in cardiovascular system. Maintenance of normal blood pressure although suggests normal cardiac function and peripheral perfusion of oxygen and nutrients in early stages of illness, body’s compensatory autoregulatory mechanisms can maintain normal blood pressure, and the underlying disease state or early potential life threatening state may be overlooked.
Respiration :
It is probably the most important vital parameter in pediatric medicine. Further most of other pediatric admissions and intensive care admissions have secondary affection of respiratory system by derangement of neuro metabolic system.
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