1.1 Approach to the Paediatric Patient
* Ian Everitt * Andrew Jan * Andrew Harris * Tom Everitt * Lisa Coutts *
Paediatric patients can generally be divided into three broad groups: the obviously well, the obviously sick or the potentially sick child…. it is by a ‘filtering process’ via history, examination, observation, investigation and consultation that one identifies the potentially sick child.
Some young children with bacteraemia… can appear completely well apart from fever.
… inflammatory markers are unfortunately often non-discriminatory between benign and serious causes.
In children less than one month, any fever is significant, whereas older children are more at risk of serious illness with higher temperatures. Likewise, hypothermia can occur in overwhelming sepsis, particularly in neonates and infants.
The younger the child, the greater the potential for rapid deterioration as the early manifestations of a serious illness may be subtle and non-specific. One must be vigilant for the early signs of compensated shock such as tachycardia, decreased capillary refill, mottled skin, cool peripheries, decreased urine output, or drowsiness.
An important principle in emergency paediatrics is to be proactive. One must be aware of the importance of regularly reviewing a child’s response to a given therapy, escalate treatment if required and be vigilant for subtle signs of deterioration.
A few initial moments gaining a child’s confidence… will usually reward the doctor [or nurse] with a more rapid and thorough assessment of the reluctant child.
…if a child is to undergo a procedure during which he may become distressed, such as intravenous insertion of laceration repair, it is best performed in a closed dedicated procedure room. This will avoid visual or auditory distress to other children and parents.
For neonates and small infants a radiant heater over the examination bed will aid in temperature stability, examination and often the discovery of veins for cannulation.
In mixed emergency departments where triage nurses may have had less paediatric experience, there has been a tendency to up-triage paediatric patients. The use of scoring systems for specific conditions or a Triage Observation Tool may be helpful in improving the reliability of triage in younger children, who may present with non-specific symptomatology.
It is important that children with pain are given early and appropriate analgesia or have injuries splinted when required… The use of opiates, when required, will only enhance, rather than detract from the subsequent physician’s physical examination.
An understanding of the concept of ‘the fourth trimester’ is useful in dealing with crying phenomena in the first months of life, which will often precipitate emergency department visits.
When explaining procedures to a child it is important to be age appropriate and above all honest… Maintaining a child’s trust at all times is crucial and will positively influence any subsequent medical contacts the child may have.