The Acutely Unwell Child

A child is not simply a little adult, so do not treat them like one.

Blood volume is around 80ml/kg.

As well as the above differences, it is important to remember that a child has a relatively large surface area compared to body volume and a high anterior larynx/floppy epiglottis.

Common presenting illnesses

Note that the acute management (below) is the same for any acutely unwell child.

• Bronchiolitis/URTI/croup (28%)
• Gastroenteritis (8.8%)
• Seizures/epilepsy (6.6%)
• Pneumonia/LRTI (6.2%)
• Asthma (5.7%)
• Viral illness (5.2%)
• Head injury (2.3%)
• Abdominal pain (3.5%)
• UTI (2.2%)

Management

1. Airway
   1. Open and normal- loud crying or speaking to you etc
   2. Compromised- if they are unconscious, a child’s airway is always compromised due to relatively large tongue and floppy epiglottis.  Alternatively, if they have vomited/bled in the mouth.  The use of head tilt/chin lift, suction and adjuncts are all recommended in maintaining an airway.
   3. Obstructed- if the child is conscious then cough encouragement, back slaps (5) and thrusts (5 chest for infant <1yr or 5 abdo for >1yr).  If unconscious, the obstruction should be removed where possible (e.g. with suction)
2. Breathing
   1. Look, listen, feel
   2. 
   3.  Look for the effort of breathing, the effect of breathing and the efficacy of breathing (3 E’s)
   4. Give oxygen and listen to the chest.
3. Circulation
   1. Assess pulse rate (see above for normal), temperature, BP (note HYPOTENSION IS A PRETERMINAL SIGN- over 40% blood loss), capillary refill is often more useful than BP, Urine output (<2ml/kg/hr in infants and <1ml/kg/hr in children is abnormal)
   2. To manage, if large bore IV access impossible, intra-osseous (tibia) access may be a useful alternative- give 20ml/kg of 0.9% saline (unless contraindicated)
      1. AT THIS POINT, REASSESS IF NOT or SLOWLY IMPROVING
4. Disability/Glucose
   1. Check BM
   2. AVPU; Pupils; Neurological exam
5. Exposure
   1. Remember to check front and back; check patient notes, minimise heat loss, document findings etc