HOW TO APPROACH ILL PEDIATRIC PATIENT

The emergency department (ED) sees between 30% and 35% of patients who are younger than 18 years old. Most of these kids can't get to the primary provider's office and need urgent treatment or office care for self-contained diseases. As a result, people come to the ED for treatment. 

True emergencies, in which children could die or suffer major disabilities if not treated right away, account for between 3 and 6 percent of ED visits.

CLINICAL FEATURES

Experienced pediatric emergency physicians frequently refer to children in urgent need of assessment as "septic" or "sick," as they quickly make the assessment based on a constellation of symptoms and indications that are challenging to teach without first-hand experience.

Signs and Symptoms of a Sick Child

— Lethargy with little or no apprehension to examination or painful procedures; failure to interact appropriately with their environment.

— Drooling or stridor with severe air hunger.

— Cyanosis of lips and extremities with poor perfusion and absent pulses in the lower extremities.

— Extreme hypotension

— Irritability, particularly when held by parents, with the inability to be comforted

— Poor feeding is associated with a weak suck and poor interest in feeding

— Elevated temperature or hypothermia.

— Poor capillary refill with mottled skin appearance or poor turgor.

— Persistent vomiting with or without feedings.

— Complaint of headache and photophobia (in older children); the stiff neck is not a reliable sign in children younger than 18 months, and these children are unlikely to be able to report subjective complaints.

— Seizures may be prolonged or focal and are often associated with fever.

— Altered mental status, particularly with combativeness or inappropriate thoughts.

— Respiratory distress, particularly with nasal flaring, grunting respirations, tachypnea, intercostal and subcostal retractions, or diaphragmatic breathing.

— Any presentation of trauma that may be associated with a blunt injury to the head or thorax or with a penetration injury to the chest.

— Petechiae or purpura associated with fever.

— Weak cry or no cry when painful procedures or examination maneuvers are performed.

DIFFERENTIAL DIAGNOSES

Children who suffer true, life-threatening emergencies fall into several distinct categories of illness. Children with any of the following life-threatening emergencies usually have initial respiratory compromise resulting from increased metabolic demands and cardiac compromise as a secondary event:

— Acute respiratory distress

— Cardiovascular disorders

— Environmental injuries

— Injuries and emergencies with altered states of consciousness

— Shock syndromes

— Traumatic disorders