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Initial assessment and stabilization of children with respiratory or circulatory compromise

Initial assessment and stabilization of children with respiratory or circulatory compromise
Literature review current through: Jan 2024.
This topic last updated: Apr 19, 2023.

INTRODUCTION — The initial evaluation of critically ill children must quickly identify those with respiratory or circulatory compromise. Early recognition and treatment of a patient with deficiencies in oxygenation, ventilation, or perfusion frequently prevents deterioration to respiratory or cardiac arrest. Outcomes for children who develop cardiopulmonary arrest are poor [1,2].

This topic will review the clinical features that rapidly identify children with respiratory failure or circulatory compromise. Priorities for initial stabilization are presented.

Airway management techniques, including rapid sequence intubation (RSI), are discussed separately. (See "Basic airway management in children" and "Technique of emergency endotracheal intubation in children" and "Rapid sequence intubation (RSI) in children for emergency medicine: Approach".)

More detailed discussions of assessment of circulation and the definition and treatment of shock are also discussed in detail elsewhere. (See "Assessment of systemic perfusion in children" and "Pathophysiology and classification of shock in children".)

INITIAL ASSESSMENT — Most children with respiratory or cardiovascular compromise can be easily recognized during a rapid initial assessment. Obvious examples include children with respiratory conditions such as severe asthma exacerbations, or inadequate perfusion, such as hypovolemic shock. (See "Assessment of systemic perfusion in children".)

Children with subtle features of physiologic compromise can also be identified with a systematic evaluation of key clinical findings. Frequent reevaluation and close monitoring are essential to quickly recognize those whose conditions are deteriorating.

Throughout the evaluation, interventions to provide oxygen, support ventilation, and improve perfusion should be promptly administered as indicated. A detailed physical examination and ancillary studies, such as pulse oximetry and end-tidal CO2 (ETCO2) monitoring, will determine the need for more aggressive supportive care and guide treatment of the underlying condition.

Pediatric assessment triangle — The pediatric assessment triangle (PAT) is a rapid assessment that relies on three observations to quickly identify a child with respiratory or circulatory compromise, or both, who requires immediate supportive care and has shown high reliability when used in pre-hospital and hospital settings [3-7]:

Appearance

Breathing

Circulatory status

In addition to recognizing children who require stabilization with respiratory or cardiovascular interventions, the PAT also identifies most children with a serious illness who should receive prompt evaluation. A child in respiratory failure may have abnormal work of breathing with either abnormal appearance or circulation, while a patient with abnormalities in all three of the components of the PAT is likely in impending cardiopulmonary arrest. In comparison, an infant with an abnormal appearance alone may be physiologically stable but have a life-threatening infection, such as meningitis.

Appearance — Young children in an unfamiliar environment can be agitated, crying, or resist examination. Such patients must be distinguished from children who are restless or anxious as the result of hypoxia, or somnolent from hypercarbia, severe hypoxia, or shock. The following characteristics of a child's appearance (the "TICLS" mnemonic) help the clinician distinguish between a developmentally appropriate response and signs of serious illness [7]:

Tone – What is the infant's muscle tone? Vigorous movement and normal muscle tone are reassuring. In comparison, children who are seriously ill may have decreased muscle tone or appear limp and weak.

Interactiveness – Is the child playful and interactive, or indifferent to distractions in the environment? A child who will reach for a toy or exhibit developmentally appropriate stranger anxiety is less worrisome than one who does not respond to a caregiver or appropriately resist examination.

Consolability – Can the infant be consoled or distracted by a parent or caregiver? Crying may be a nonspecific symptom that indicates anxiety or hunger, rather than severe discomfort.

Look/gaze – Does the infant or child focus on people or objects in the environment, or is the gaze unfocused? An unresponsive stare suggests an altered mental status.

Speech/cry – Is the crying loud and strong, or weak [6-8]? Similar to decreased muscle tone, a weak cry is an important indication of serious illness. In addition, a hoarse or muffled voice suggests upper airway obstruction.

A child who is alert, easily consolable when crying, has good muscle tone, and responds to a caregiver is unlikely to be critically ill. On the other hand, the clinician should be very concerned about an infant who is limp, not interactive, listless, and has a weak cry.

Work of breathing — Children with deficiencies in oxygenation and/or ventilation may have some evidence of respiratory compromise, as indicated by increased work of breathing. Decreased work of breathing may be noted as the patient becomes fatigued and progresses toward respiratory failure and respiratory arrest.

Assessment of airway sounds, the child's position of comfort, and use of accessory muscles provides information regarding the patient's work of breathing.

Airway sounds – Abnormal airway sounds that can be heard without a stethoscope are often an indication of respiratory distress. These include stridor, snoring, grunting, and wheezing.

Positioning – To maximize airway opening when there is obstruction, a child may assume the "sniffing position" (neck flexed, head mildly extended) to align the airway axes and improve airflow. For older children, the tripod position, in which the child is sitting up and leaning forward on outstretched hands, may be preferred.

Accessory muscle use – Patients with inadequate oxygenation or ventilation often use accessory muscles (such as supraclavicular, intercostal, and/or substernal groups) to increase tidal volume, thereby improving minute ventilation. Retractions result from the use of accessory muscles. They can be supraclavicular, intercostal, and/or substernal. Severe retractions of more than one muscle group indicate significant hypoxia.

Head bobbing (extension of the head on inhalation and forward movement on exhalation) and nasal flaring (opening of the nostrils to allow the passage of more air) are additional indicators of accessory muscle use and respiratory distress [6,8].

A child who has abnormal breathing sounds, is in a position to maximize airflow, and is using accessory muscles is in respiratory distress.

These features are described in detail elsewhere. (See "Acute respiratory distress in children: Emergency evaluation and initial stabilization", section on 'Physical examination'.)

Circulation to the skin — Pallor or cyanosis is a worrisome finding that may indicate hypoxemia or inadequate perfusion to the skin. Poor capillary refill or cool skin also occurs with poor perfusion. (See "Assessment of systemic perfusion in children", section on 'Skin appearance'.)

However, cool environmental temperatures can cause peripheral vasoconstriction in healthy young infants, resulting in a mottled appearance to the skin in an infant who has normal circulation. Similarly, acrocyanosis (as the result of vasomotor instability) may be a normal finding in infants less than two months of age [6,8].

Physical examination — Following the rapid initial assessment (PAT) and initiation of appropriate supportive care, a thorough physical examination should be performed. This information may identify the underlying condition and guide specific treatment. In addition, it establishes a baseline from which changes in the child's condition can be recognized and supportive care and specific treatment modified. As an example, the condition of a child who was initially in severe respiratory distress with an anxious appearance and now has decreased work of breathing and lethargy has deteriorated from respiratory distress to respiratory failure. The patient may now require assisted ventilation, as well as supplemental oxygen.

Vital signs should be obtained, particularly respiratory rate, heart rate, blood pressure, and pulse oximetry. Weight in kilograms should also be recorded whenever possible.

Estimation of weight — An accurate weight may not be available for a child who requires weight-based interventions such as medications and fluid resuscitation. Health care provider weight estimates can be inaccurate [9]. While parent or primary caregiver estimation is most accurate (within 10 percent of actual body weight approximately 80 percent of the time), they frequently are not available during pediatric resuscitation.

When parent/primary caregiver estimation is not available, we recommend the use of length-based measurements (eg, Broselow, Handtevy, PAWPER, or Mercy tapes) rather than age-based methods. In a systematic review of 80 studies, the Broselow tape provided a weight estimate within 10 percent of actual weight 54 percent of the time while the Mercy tape was accurate in 70 to 77 percent of patients [9]. By contrast, in a retrospective evaluation of age-based formulas in over 1000 children from South Africa, weight predicted by age-based formulas had critical errors (>20 percent difference from actual weight) 25 to 70 percent of the time, depending upon the specific formula used [10].

These methods may underestimate the child's actual weight, especially for those over 25 kg living in resource-rich regions [11-17]. By contrast, among children in resource-limited settings, length-based methods may significantly overestimate weigh [9]. The PAWPER tape, which uses WHO weight-for-length data has body habitus adjustments for very thin to obese children, and has performed well [18]. In a separate study, habitus adjustment of length-based formulas improved accuracy by 40 percent [10].

Regardless, because most resuscitation drugs have a volume of distribution associated with lean weight, length-based methods provide reasonable estimates when weights cannot be measured [9].

If neither parent/primary caregiver estimation nor length-based methods are available, age-based methods can be used but will often be highly inaccurate [10]. Of the age-based formulas, the modified European Pediatric Life Support formula appears to perform best:

1 to 10 years of age: weight (kg) = 2 X (age in years + 4)

Key assessments — Essential aspects of the physical examination include the following:

Respiratory evaluation – The respiratory rate and pattern of respiration should be noted. Auscultatory findings provide essential information regarding tidal volume and localized disease processes (upper versus lower airway sounds, symmetry of breath sounds, focally abnormal lower airway findings). A detailed discussion of the physical examination for children with respiratory distress can be found separately. (See "Acute respiratory distress in children: Emergency evaluation and initial stabilization", section on 'Physical examination'.)

Cardiac examination – Heart rate, blood pressure, and evaluation of end organ perfusion provide a more precise evaluation of the child's circulatory status (see "Assessment of systemic perfusion in children"). In addition, abnormal heart sounds (such as a gallop rhythm or a murmur) may indicate a cardiac etiology, such as heart failure, for the child's condition.

Neurologic assessment – Level of consciousness provides an important indication of brain perfusion. It can be quickly categorized using the AVPU scale, where A is alert, V responds to verbal commands, P responds to painful stimuli, and U is unresponsive. Abnormal mental status may result from a non-neurologic cause (such as hypoxia or hypovolemic shock) or from a primary neurologic disorder. Focal findings consistent with a neurologic process include abnormalities in pupillary light response, extraocular movements, or motor activity.

Skin – Examination of the skin may provide information regarding the patient's circulatory status, as well as clues to a specific underlying condition. For instance, petechiae or purpura indicates an infectious process such as meningococcemia, while urticaria suggests anaphylaxis.

Ancillary studies — The PAT and physical examination identify many of the critically ill children who require airway support. Pulse oximetry provides rapid quantitative information regarding oxygenation. The addition of noninvasive bedside technology to measure end-tidal CO2 allows the clinician to quickly identify patients with inadequate ventilation as well.

Noninvasive measures of oxygenation and ventilation have limitations. Therefore, arterial samples may be required to accurately assess oxygenation and ventilation for some patients.

Pulse oximetry — Pulse oximetry is a noninvasive technique in which a sensor is placed on the skin (usually a digit or ear lobe). The sensor then measures the absorption of light by oxygenated and deoxygenated hemoglobin to determine the percent of hemoglobin that is saturated with oxygen. The spectrophotometric principles of pulse oximetry are discussed elsewhere. (See "Pulse oximetry", section on 'Principles and equipment'.)

Pulse oximetry should be monitored continuously for measurements at or below 94 percent. Within the range of PaO2 that represents clinically significant hypoxemia, small changes in the level of saturated hemoglobin reflect much larger decreases in PaO2 (figure 1). As an example, a SpO2 of 98 percent correlates with a PaO2 of approximately 100 mmHg, 95 percent with 80 mmHg, and 90 percent with 60 mmHg; the last value is a level that represents clinically significant hypoxia.

Technical difficulties such as improper placement of the sensor or motion can create artifacts that make the oximeter reading unreliable. In addition, low perfusion states, the presence of abnormal hemoglobin (such as carboxyhemoglobin or methemoglobin), and anemia can also result in inaccurate pulse oximetry readings. (See "Respiratory support, oxygen delivery, and oxygen monitoring in the newborn", section on 'Pulse oximetry' and "Pulse oximetry" and "Pulse oximetry", section on 'Troubleshooting sources of error'.)

End-tidal carbon dioxide measurement — Capnographic devices measure end-tidal CO2 (ETCO2) and display fluctuations in levels over the ventilatory cycle as a waveform [19]. They are routinely used for intubated patients to confirm endotracheal tube placement and monitor ventilation. With a sidestream sampling technique, ETCO2 measurement can also be used to assess ventilation in non-intubated patients [20-22].

ETCO2 measurement should be used, when available, to evaluate ventilation for any patient who may be at risk to develop respiratory failure. It is particularly valuable for those receiving supplemental oxygen who can experience a significant decrease in ventilation without a noticeable change in oxygen saturation, such as patients who are undergoing sedation [19,23]. ETCO2 monitoring is reviewed in detail separately. (See "Carbon dioxide monitoring (capnography)".)

Transcutaneous CO2 measurement — Transcutaneous measurement of CO2 has been used primarily for neonates and in the operating room for infants and children up to 16 years of age [20,24]. With this method, a heated electrode, placed on the skin, measures changes in pH as a result of CO2 that has diffused from capillary beds to the skin. CO2 levels are extrapolated from this measurement.

Similar to ETCO2, transcutaneous CO2 measurement (TCO2) can be useful to correlate clinical assessment with ventilatory status. In one prospective study, an excellent correlation between TCO2 measurements and PaCO2 values from simultaneously obtained arterial samples was noted [20]. However, TCO2 can be difficult to use in emergency situations because it requires time to calibrate. In addition, transcutaneous CO2 measurement is unreliable in shock, hypothermia, and for patients who are receiving vasoconstrictor medications [24].

Arterial blood gas/venous blood gas — Accurate information regarding a critically ill patient's oxygenation, ventilation, and acid base status is an essential determinant of optimum management. Sampling of arterial blood should be performed in the following circumstances:

To assess ventilation when ETCO2 or TCO2 measurements are not available

To correlate with trends in noninvasive monitoring

To measure PaO2 and PaCO2 when noninvasive measurements may be inaccurate

An arterial sample that is handled properly provides the most accurate information regarding a patient's oxygenation, ventilation, and acid base status. The technique for performing an arterial puncture and specimen handling are discussed separately, as is the interpretation of blood gas results. (See "Arterial puncture and cannulation in children" and "Measures of oxygenation and mechanisms of hypoxemia".)

Venous pH generally correlates well with arterial pH. However, the correlation between venous and arterial PaCO2 and PaO2 is not sufficient to provide an accurate assessment of ventilation and oxygenation in critically ill patients [25,26].

INITIAL STABILIZATION — Children who have abnormalities identified using the pediatric assessment triangle (PAT) are critically ill and require immediate intervention. Information from the physical examination and/or ancillary studies may also provide indications for respiratory or circulatory support.

Supplemental oxygen — Supplemental oxygen should be considered for any child who appears seriously ill, as determined by the PAT (appearance, breathing, circulation). As a general rule, patients with two or more abnormalities in the PAT require oxygen therapy. In addition, most patients with an oxygen saturation ≤94 percent should receive supplemental oxygen.

For children who are breathing spontaneously, low concentrations of oxygen can be delivered by blow-by, nasal cannula, or a simple face mask. The choice of delivery system depends on factors such as the dose of oxygen required and how well the child accepts the device. A nonrebreather mask with reservoir is required to deliver higher concentrations. (See "Continuous oxygen delivery systems for the acute care of infants, children, and adults".)

Pulse oximetry should be monitored for patients who are receiving supplemental oxygen.

Assisted ventilation — Children with apnea or bradypnea require assisted ventilation. Others who need ventilatory support may only be identified by CO2 measurement, either from an arterial blood gas or with ETCO2 or TCO2 measurement. As an example, a child with status epilepticus who is breathing spontaneously and receiving supplemental oxygen may have an elevated ETCO2 or TCO2 with an oxygen saturation of 100 percent. Similarly, an infant with a respiratory rate of 70 and a TCO2 measurement of 50 has significant respiratory compromise despite a pulse oximetry reading of 98 percent.

Assisted ventilation should initially be provided with bag-mask ventilation (BMV). Endotracheal intubation may be necessary for those who are not expected to improve quickly. (See "Basic airway management in children", section on 'Assisted ventilation' and "Technique of emergency endotracheal intubation in children".)

As a note of caution, children who resist BMV should be given supplemental oxygen and re-evaluated. Rapid sequence intubation (RSI) should be considered for those who continue to have poor ventilation. (See "Rapid sequence intubation (RSI) in children for emergency medicine: Approach".)

Circulatory support — Patients with inadequate perfusion as indicated by decreased mental status, poor skin perfusion, and/or abnormal vital signs are in shock. Vascular access should be established, and they should receive fluid resuscitation. Vascular access and the initial management of shock are discussed elsewhere. (See "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies" and "Intraosseous infusion" and "Shock in children in resource-abundant settings: Initial management".)

Monitoring — Children who are critically ill require frequent assessment and continuous monitoring of vital signs, particularly heart rate and pulse oximetry. This is essential to evaluate the effectiveness of interventions and to identify clinical deterioration.

SUMMARY AND RECOMMENDATIONS

Rapid identification and stabilization of critically ill children with respiratory or circulatory compromise are essential components of evaluation and management. Critically ill children who require immediate stabilization of respiratory and circulatory function can generally be identified through the following evaluation (see 'Initial assessment' above):

Pediatric assessment triangle (PAT) – The three components of the PAT are appearance, breathing, and circulation. (See 'Pediatric assessment triangle' above.)

-Appearance – Children who require prompt supportive care may have abnormal tone, decreased interactiveness, poor color, abnormal stare, or a weak cry.

-Breathing – Abnormal airway sounds, a position of comfort that maximizes airway opening, and use of accessory muscles indicate increased work of breathing.

-Circulation to the skin – Pallor or cyanosis may occur with decreased perfusion as well as with hypoxemia. Poor capillary refill or cool skin also indicates poor perfusion.

A thorough physical examination, with attention to assessment of respiratory, cardiovascular, neurologic functions, and skin provides additional information to guide assessment and treatment. (See 'Physical examination' above.)

Parent/primary caregiver estimation of weight is most accurate when an actual weight is not available. When this estimation is not available, we recommend the use of length-based measurements (eg, Broselow, PAWPER, or Mercy tapes) rather than age-based methods. (See 'Estimation of weight' above.)

Pulse oximetry and end-tidal or transcutaneous CO2 measurement often provide a rapid noninvasive evaluation of oxygenation and ventilation. However, an arterial sample provides the most accurate measurement of PaO2, PaCO2, and pH. (See 'Ancillary studies' above.)

The initial stabilization of the critically ill child must occur concurrently with evaluation and treatment of the underlying condition. We suggest the following approach (see 'Initial stabilization' above):

Most children with two or more abnormalities in the PAT or an oxygen saturation ≤94 percent should receive oxygen therapy.

Oxygen should be provided at the highest concentration available through whatever device the child tolerates. (See "Continuous oxygen delivery systems for the acute care of infants, children, and adults".)

Children with respiratory failure or impending respiratory arrest (as suggested by apnea, bradypnea, or an irregular respiratory pattern) should initially receive bag-mask ventilation. Further airway management, including endotracheal intubation, may be required. (See "Basic airway management in children" and "Technique of emergency endotracheal intubation in children".)

Critically ill children should be closely monitored with frequent vital signs and pulse oximetry to evaluate the effectiveness of interventions and to identify clinical deterioration. (See 'Monitoring' above.)

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