CHAPTER 1
Introduction and structured approach to paediatric emergencies

Learning outcomes

After reading this chapter, you will be able to:

• Appreciate the focus and principles of the APLS course
• Describe the structured approach to identifying and managing paediatric emergencies
• Identify the important differences in children and the impact these have on the management of emergencies
• Appreciate that the absolute size and relative body proportions change with the age of the child
• Identify the approach to triage of a child

1.1 Introduction

The Advanced Paediatric Life Support (APLS) course equips those caring for children with the necessary skills and structured approach to identify and safely manage ill or injured children whenever or wherever they encounter them.

Children continue to die from preventable causes throughout the world. The reasons for their deaths differ between countries, however the structure and principles for managing the underlying causes are universal.

Child mortality is the lowest it has ever been and has halved in the last three decades, which is a huge achievement (12.5 million deaths of under 5-year-olds worldwide in 1990 compared with 5 million in 2020).

Worldwide data from the World Health Organization (WHO) show the leading cause of death in this age group is pneumonia, followed by preterm birth and then diarrhoeal illnesses. This compares with recent data from the USA showing the leading cause in children to be gun-related injuries. In the UK, Office for National Statistics (ONS) data show that cancer is the leading cause of death in all children followed by accidents and then congenital abnormalities.

The COVID-19 pandemic has not directly had a significant impact on child mortality. However, there are ongoing concerns about the indirect impact due to strained and under-resourced health systems; a reduction in care-seeking behaviours; a reduced uptake of preventative measures such as vaccination and nutritional supplements; and socioeconomic challenges.

1.2 The APLS approach

In the structured approach it is essential to remember that:

• The child's family will need support from a qualified member of the team
• Absolute size and body proportions change with age
• Observations and therapy in children must be related to their age and weight
• The psychological needs of children must be considered
• It is key to support each other as the clinical team

Physiological differences

Children, especially young ones, have significantly lower physiological reserves than adults. As a consequence, they may deteriorate rapidly when severely ill or injured and respond differently from adults to various interventions. It is essential to manage and support their respiratory and cardiovascular systems in a timely and structured manner to prevent further deterioration or even cardiovascular arrest. (See normal ranges table, inside front cover.)

Relationship between disease progression and outcomes

The further a disease process is allowed to progress, the worse the outcome is likely to be. The outcomes for children who have a cardiac arrest out of hospital are generally poor. This may be because cardiac arrest in children is less commonly related to cardiac arrhythmia, but is more commonly a result of hypoxaemia and/or shock with associated organ damage and dysfunction. By the time that cardiac arrest occurs, there has already been substantial damage to various organs. This is in contrast to situations (more common in adults) where the cardiac arrest is the consequence of cardiac arrhythmia - with preceding normal perfusion and oxygenation. Thus the focus of the course is on early recognition and effective management of potentially life-threatening problems before there is progression to respiratory and/or cardiac arrest (Figure 1.1).

Figure 1.1 Pathways leading to cardiac arrest in childhood (with examples of underlying causes)

ICP, intracranial pressure

Standardised structure for assessment and stabilisation

A standardised approach for resuscitation enables the provision of a standard working environment and access to the necessary equipment to manage ill or injured children. The use of the standardised structure enables the whole team to know what is expected of them and in which sequence.

Once basic stabilisation has been achieved, it is appropriate to investigate the underlying diagnoses and provide definitive therapy.

Definitive therapy (such as surgical intervention) may be a component of the resuscitation

Resource management

Provision of effective emergency treatment depends on the development of teams of healthcare providers working together in a coordinated, well-led manner (Figure 1.2). It is important that all training in paediatric life support focuses on how to best use the equipment and human resources available and emphasises the key nature of effective communication.

Figure 1.2 Advanced paediatric life support (APLS) in action

Early referral to appropriate teams for definitive management

Emergency departments are unlikely to be able to provide definitive management for all paediatric emergencies, and a component of stabilisation of critically ill or injured children is the capacity to call for help as soon as possible, and where necessary transfer the child to the appropriate site safely.

Ongoing care until admission to appropriate care

In most parts of the world it is impossible to transfer critically ill children into intensive care units or other specialised units within a short time of their arrival in the emergency area. Therefore, it is important to provide training in the ongoing therapy that is required for a range of relatively common conditions once initial stabilisation has been completed.

1.3 Important differences in children

Children are a diverse group, varying enormously in weight, size, shape, intellectual ability and emotional responses. At birth a child is, on average, a 3.5 kg, 50 cm long individual with small respiratory and cardiovascular reserves and an immature immune system. They are capable of limited movement, have immature emotional responses though still perceive pain and are dependent upon adults for all their needs. At the other end of childhood, the adolescent may be more than 60 kg, 160 cm tall and look physically like an adult, often exhibiting a high degree of independent behaviour but who may still require support in ways that are different from adults.

Competent management of a seriously ill or injured child who may fall anywhere between these two extremes requires a knowledge of these anatomical, physiological and emotional differences and a strategy of how to deal with them.

Weight

The most rapid changes in weight occur during the first year of life. An average birth weight of 3.5 kg will have increased to 10 kg by the age of 1 year. After that time weight increases more slowly until the pubertal growth spurt. This is illustrated in the weight charts shown in Figure 1.3.

As most drugs and fluids are given as the dose per kilogram of body weight, it is important to determine a child's weight as soon as possible. The most accurate method for achieving this is to weigh the child on scales; however, in an emergency this may be impracticable. Very often, especially with infants, the child's parents or carer will be aware of a recent weight. If this is not possible, various formulae or measuring tapes are available. The Broselow or Sandell tapes use the height (or length) of the child to estimate weight. The tape is laid alongside the child and the estimated weight read from the calibrations on the tape. This is a quick, easy and relatively accurate method. Various formulae may also be used although they should be validated to the population in which they are being used.

If a child's age is known, the normal ranges table will provide you with an approximate weight (inside front cover) and allow you to prepare the appropriate equipment and drugs for the child's arrival in hospital. Whatever the method, it is essential that the carer is sufficiently familiar with the tools to use them quickly and accurately under pressure. When the child arrives, you should quickly review their size to check if it is much larger or smaller than predicted. If you have a child who looks particularly large or small for their age, you can go up or down one age group.

Figure 1.3 Example of centile chart for weight in girls (2-18 years)

©Reproduced with kind permission of RCPCH and Harlow Printing Limited

Anatomical

As the child's weight increases with age the size, shape and proportions of various organs also change. Particular anatomical changes are relevant to emergency care.

Airway

The airway is influenced by anatomical changes in the tissues of the mouth and neck. In a young child the occiput is...