🩺 Chapter 1: Approach to a Sick Child

Paediatric Advanced Life Support (PALS) · Evaluate-Identify-Intervene · ABCDE · Respiratory distress vs failure · Compensated vs hypotensive shock

🔍 Core Concepts: Rapid Recognition of the Sick Child

🚨 Initial impression (doorway)
Consciousness, breathing work, skin colour (cyanosis/pallor/mottling). Unresponsiveness + abnormal breathing + colour → emergency response + CPR if pulseless.
📋 Evaluate-Identify-Intervene
Primary assessment: ABCDE (Airway, Breathing, Circulation, Disability, Exposure). Identify: respiratory distress vs failure, compensated vs hypotensive shock, cardiorespiratory failure.
🫁 Respiratory categories
Respiratory distress: ↑work of breathing, SpO2 >94%. Respiratory failure: ↑work of breathing, SpO2 not maintained ± O2, +/- hypoventilation.
Interventions: position, airway manoeuvres, O2, bag-mask, intubation.
❤️ Circulatory categories
Compensated shock: tachycardia, poor perfusion, normal BP. Hypotensive shock: BP low (decompensated). Fluid bolus 20 ml/kg isotonic, reassess, IO if no IV access in 90 sec. Vasoactive support.
⚠️ Disability & Exposure
GCS/AVPU, pupils (size/reaction). Exposure: fever, rashes, ecchymosis. Head-to-toe after stabilisation. SAMPLE history: symptoms, allergies, meds, PMH, last meal, events.
💡 Key Pearls
Children arrest from respiratory failure/shock, not primary arrhythmia. Life-threatening events: apnoea, cardiac arrest, hypotension, arrhythmias → activate emergency response immediately. ETCO2, lactate, ScvO2 guide resuscitation.

🩺 Step-by-Step: Approach to a Sick Child (PALS)

1
Initial impression (doorway)
Assess consciousness, breathing (increased/gasping/absent), colour (cyanosis, pallor). Life-threatening? If apnoea/pulseless → activate emergency response, start CPR (C-A-B).
2
Primary assessment (ABCDE)
A: Airway patent? head-tilt chin-lift/jaw thrust if C-spine injury. Suction/adjuncts.
B: Breathing rate, retractions, air entry, SpO2. Classify distress vs failure.
C: Circulation: HR, pulses (central/peripheral), CRT, BP. Compensated vs hypotensive shock.
D: Disability: GCS/AVPU, pupil size/reaction.
E: Exposure: temperature, rash, ecchymosis.
3
Identify physiological category
• Respiratory distress: ↑work of breathing, SpO2 >94% on room air.
• Respiratory failure: SpO2 <90% despite O2, or hypoventilation.
• Compensated shock: tachycardia, delayed CRT, cool extremities, BP normal.
• Hypotensive shock: low BP + signs of shock.
4
Interventions (immediate)
• Airway: reposition, suction, oropharyngeal/nasopharyngeal airway, consider intubation if failure.
• Breathing: O2, bag-mask ventilation, NIV if needed.
• Circulation: IV/IO access. Fluid bolus 20 mL/kg isotonic crystalloid, reassess. Start vasoactive drugs for fluid-refractory shock.
• Monitoring: pulse ox, ETCO2, multichannel monitor, lactate.
5
Secondary assessment & diagnostics
SAMPLE history + head-to-toe exam. Labs: ABG, lactate, electrolytes, blood culture, CXR, echo if shock persists. Reassess after each intervention. Escalate to PICU.
6
Key emergency triggers
Apnoea, gasping, HR <60 with poor perfusion, hypotension unresponsive → CPR, epinephrine, consider defibrillation if shockable rhythm.