Download PDF of Paediatric Early Warning Score (EWS) chart (1.2MB)

You assess airway patency by:
• looking for chest and/or abdominal movement,
• listening for breath sounds and
• feeling for expired air.

You are reassured to note that you can see his chest moving, you can hear breath sounds and feel the expired air.

James airway is patent and does not require an adjunct at this point. There are no signs of airway obstruction and you therefore move on to breathing.

• You inspect the patient for gasping and check the oxygen saturation monitor.
• You assess effort of breathing by assessing: respiratory rate, recessions, accessory muscle use and flaring of nostrils.
• You palpate the trachea to ensure it is central.
• You auscultate for equal air entry and added sounds (e.g. stridor, wheezing and/or grunting)

The nurse informs you that his saturations were 89% in air and that she has started some oxygen with a non-rebreathe face-mask (i.e. high flow oxygen) and that they are now 99%. He is tachypnoeic with a respiratory rate of 44rpm. His trachea is central and he has moderate intercostal recession. He has reduced air entry at the right base which is associated with overlying dullness. There are no extra breathing sounds.

Right lower lobe collapse and/or pneumonia are the most likely diagnosis.  This is likely to represent a post-operative complication in a patient who is high risk because of a neuro-disability. 

James has also had an operative procedure and is immobile.  You therefore consider a differential diagnosis of pulmonary embolus, however this is relatively rare in children. 

• His breathing does not currently require support with a bag-valve mask device (BVM) (e.g. AMBU ® bag)
• He is already on O₂ 15 L/min via a non-rebreathe mask resulting in good oxygen saturations.
• You want to perform a blood gas (BG) – As he is a child you choose not to perform an arterial blood gas. You decide you are going to take a venous blood gas when you insert a venous cannula. It would also be valid to take a capillary blood gas if venous sampling was not possible.
• You ask one of the nurses to call the radiology department to attend for a portable Chest X-ray (CXR)

• No - Opioid excess can cause respiratory depression. This would result in a low respiratory rate. Fever and pain can make children tachycardic and/or tachypnoeic and these need to be considered in your assessment.
• You move on to assess his circulation.

• Vital signs:
  • Heart rate
  • Pulse volume
  • Blood pressure
  
  
• Skin & Mucous membrane perfusion:
  • Capillary refill time (central & peripheral)
  • Temperature
  • Colour
  
  
• Organ Perfusion:
  • Effects on breathing
  • Mental status
  • Urine output
  
  

He is tachycardic with a heart rate of 160bpm. The pulse volume is normal. His blood pressure is 95/60mmHg. His peripheries are cool. He has a central CRT of 3 seconds and a peripheral CRT of 4 seconds. He looks pale. His mother reports that he is more drowsy then usual. He has not passed urine in the last 6 hours.

A raised heart rate which is at the extreme for age, in the absence of fever is a very ominous sign and denotes an extremely sick child that needs Senior review. His altered conscious level also make you aware that he is unwell. This child is at high risk of decompensation and therefore needs significant medical input.

• You insert a cannula and take blood tests at the same time, including:
    • blood gas (with lactate and ionised calcium). Elevated lactate is found in children who are unwell and is an important sign of significant illness.
    • glucose stick test
    • laboratory tests including full blood count (FBC), urea & electrolytes (U&Es), renal and liver function, CRP, blood culture, cross-match & coagulation studies.
  
  
• You ask the nurse to attach a cardiac monitor for continuous three lead tracing.
  
  
• You prescribe a fluid bolus
  
  
• You ask the nurse to start a strict input and output fluid chart
  

• 10mls/kg of Normal Saline (0.9%) or of a balanced crystalloid is a standard paediatric bolus. In this case you review the patients prescription chart and note that he has a weight of 24kg. You therefore give a bolus of 240mls of 0.9% normal saline.
  
  
• You move onto an assessment of his disability
  

• Patient response: alert, verbal, pain, unresponsive (AVPU)
• Pupils - size and reaction to light
• Posture
• Blood glucose
• Pupils
• Evidence of seizure activity?
  

You perform an AVPU assessment and find that he is responsive to your voice. His pupils are pinpoint and react to light. His posture is normal. His capillary blood glucose is 2.4mmol/l (should be ≥.3mmol/l)

There is no seizure activity

A bolus of sugar (dextrose) should be given if the blood sugar (BM) is less then 3mmol/l. You should give glucose (2mls/kg of 10% dextrose). This is in addition to his bolus of normal saline. It should then be followed by maintenance fluids containing glucose. You already know that James weighs 24kg. You therefore give 48mls of 10% dextrose. Maintenance fluids are covered in the Exposure chapter.

• Expose the patient (maintain dignity and minimise heat loss) to assess for injuries, signs of infection, bleeding etc.
• Check temperature
• Focused history and examination
• Chart review
• Drug chart
• Investigation results

You expose James and find no further clinical signs. His temperature is 39^o Celsius. In combination with his respiratory signs you therefore want to start intravenous antibiotics. You chose intravenous co-amoxiclav. The high fever and clinical condition could also reflect septicaemia.

You take a history from his mother who reports that he made good progress after his operation, however for the last 12 hours he “hasn’t been himself”. He has had two episodes of fever that were treated with paracetamol. His difficulty in breathing has become progressively worse. You shouldn’t underestimate the importance of listening to parental concerns. Parents are experienced in their own child’s health and what is normal for them.

• You contact your senior to inform them of the patient’s condition using an SBARR structure (see video below).
  
  
• You document this in the patient’s notes and review the patient with your senior doctor. You agree with the nurse that James can stay on the orthopaedic ward and that you will review him in 2 hours to monitor his progress.

S
It’s Sam here, I’m one of the junior doctors (FY1) on duty this evening. Is that the paediatric registrar? I’ve just reviewed a 7-year-old boy called James Lattimer who is currently on the orthopaedic ward. His nurse was worried about James as he had a fever and difficulty breathing which started earlier today and has progressively become worse.
B
James has known cerebral palsy and was admitted for scoliosis repair that he had 2 days ago. He initially had made good progress post-operatively. He was on regular paracetamol and oral morphine for post-operative pain.
A
I’ve just assessed him. He’s maintaining his own airway. He initially had saturations of 89% on air, however these are now 99% on a non-rebreathe bag at 15litres. He has a respiratory rate of 40rpm which is raised for his age. On auscultation he has reduced air entry at the right base with overlying dullness. He has a pulse rate of 160bpm which is raised for his age. This is associated with a CRT of 3 seconds and cool peripheries so I think he is shocked. The nurses felt he was a bit drowsy and he is responsive only to voice on the AVPU scale. We’ve taken a blood sugar level which was 2.4mmol/l. He is febrile with a temperature of 39^o Celsius. His Paediatric Early Warning Score is raised.
R
I’ve kept him on oxygen and I’ve ordered a chest x-ray to be performed on the ward. I’ve inserted a cannula and taken routine bloods including a venous blood gas which was normal. I’ve prescribed a bolus of 10% dextrose followed by a 10mls/kg bolus of 0.9% saline and these are being given now. We are going to monitor his fluid input/output. I think he has a post-operative pneumonia. I’ve prescribed intravenous co-amoxiclav. We’ve just repeated his observations and these have improved. I’d be very grateful if you could review the patient with me. Is there anything you would like me to do while I wait for you to arrive?