🩺 Chapter 1: Approach to a Sick Child + S.T.A.B.L.E. Module

PALS Evaluate-Identify-Intervene · ABCDE · S.T.A.B.L.E. Post-Resuscitation Care · Respiratory distress/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.

⚕️ S.T.A.B.L.E. Technique — Post-Resuscitation Stabilization

The S.T.A.B.L.E. mnemonic is essential after initial resuscitation (ABCDE) to prepare a sick infant/child for transport or ongoing care. Each component prevents secondary deterioration.

🩸 S - Sugar (Glucose)
Maintain normoglycemia (45–150 mg/dL).
• Hypoglycemia: D10W 2-5 mL/kg IV bolus, then D10 infusion.
• Hyperglycemia: avoid D10 if glucose >180; treat underlying stress, insulin rarely needed acutely.
🔍 Hypoglycemia mimics shock/seizures — always check bedside glucose.
🌡️ T - Temperature
Maintain normothermia (36.5–37.5°C).
• Hypothermia: warm environment, radiant warmer, warm IV fluids, increase ambient temp.
• Hyperthermia: antipyretics, cooling measures, treat underlying infection.
⚠️ Hypothermia worsens coagulopathy, acidosis, and increases mortality.
🫁 A - Airway
Secure and maintain patent airway.
• Position, suction, airway adjuncts. Reassess ETT position (EtCO2, CXR).
• Provide humidity, secure ETT, monitor for obstruction or displacement.
🚨 After resuscitation, re-evaluate airway continuously — most common cause of deterioration.
❤️ B - Blood Pressure
Maintain age-appropriate BP & perfusion.
• Treat hypotension with isotonic fluid boluses, vasoactive infusions (dopamine, epinephrine).
• Target MAP > 5th percentile for age.
📊 Use invasive monitoring if unstable; ScvO2 >70% indicates adequate delivery.
🧪 L - Lab Work
Timely labs guide ongoing management.
• ABG/VBG: pH, pCO2, pO2, lactate, HCO3.
• Electrolytes, iCal, Mg, Phos, BUN, Cr, glucose, CBC, coagulation profile.
• Blood culture, lactate, consider lactate clearance as resuscitation endpoint.
💞 E - Emotional Support
Family-centered care & staff debriefing.
• Keep parents informed, allow presence during stabilization when safe.
• Explain procedures, offer psychosocial support. Debrief team after critical events.
🤝 Emotional stability of caregivers improves child outcomes and reduces moral distress.
📌 Clinical Pearl: The S.T.A.B.L.E. mnemonic is performed AFTER the initial ABCDE resuscitation, before transport or PICU admission. It prevents common post-resuscitation complications (hypoglycemia, hypo/hyperthermia, unrecognized airway issues, hypotension, missed labs, and family distress).

🩺 Step-by-Step: From ABCDE to S.T.A.B.L.E. (Complete Protocol)

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, CRT, BP. Compensated vs hypotensive shock.
D: Disability: GCS/AVPU, pupil size/reaction.
E: Exposure: temperature, rash, ecchymosis.
3
Identify physiological category & intervene
• Respiratory failure → O2, bag-mask, intubation.
• Compensated shock → 20 mL/kg fluid bolus, reassess.
• Hypotensive shock → rapid fluid, IO access, vasoactive infusion.
• Cardiorespiratory failure → CPR + epinephrine per PALS.
4
Apply S.T.A.B.L.E. (Post-Resuscitation / Pre-transport)
🩸 Sugar: Check POC glucose, treat hypoglycemia (D10W 2-5 mL/kg).
🌡️ Temperature: Maintain normothermia (36.5-37.5°C).
🫁 Airway: Re-confirm ETT position, secure, humidify.
❤️ Blood pressure: Maintain MAP > age-appropriate; vasoactive drips if needed.
🧪 Lab work: ABG, lactate, electrolytes, iCal, Mg, blood gas, cultures.
💞 Emotional support: Update family, debrief team.
5
Secondary assessment & diagnostics
SAMPLE history + head-to-toe exam. CXR, echo if shock persists. Reassess after each intervention. Escalate to PICU or arrange transport.