Initial assessment and stabilization of children with respiratory or circulatory compromise
- Susan Fuchs, MD
Susan Fuchs, MD
- Professor of Pediatrics
- Northwestern University, Feinberg School of Medicine
- Section Editor
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Director, Division of Pediatric Emergency Medicine
- Associate Professor of Emergency Medicine and Pediatrics (Clinical)
- NYU School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
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 "Emergency endotracheal intubation in children" and "Rapid sequence intubation (RSI) outside the operating room in children: Approach".)
More detailed discussions of assessment of circulation and the definition and treatment of shock are also discussed in detail elsewhere. (See "Assessment of perfusion in pediatric resuscitation" and "Pathophysiology and classification of shock in children".)
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 perfusion in pediatric resuscitation".)
- Donoghue AJ, Nadkarni V, Berg RA, et al. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med 2005; 46:512.
- Ludwig S, Kettrick RG, Parker M. Pediatric cardiopulmonary resuscitation. A review of 130 cases. Clin Pediatr (Phila) 1984; 23:71.
- Horeczko T, Enriquez B, McGrath NE, et al. The Pediatric Assessment Triangle: accuracy of its application by nurses in the triage of children. J Emerg Nurs 2013; 39:182.
- Gausche-Hill M, Eckstein M, Horeczko T, et al. Paramedics accurately apply the pediatric assessment triangle to drive management. Prehosp Emerg Care 2014; 18:520.
- Dieckmann RA, Brownstein D, Gausche-Hill M. The pediatric assessment triangle: a novel approach for the rapid evaluation of children. Pediatr Emerg Care 2010; 26:312.
- American Academy of Pediatrics, American College of Emergency Physicians. APLS: The Pediatric Emergency Medicine Resource, 5th ed, Fuchs S, Yamamoto L. (Eds), Jones and Bartlett Learning, Burlington 2012.
- American Academy of Pediatrics. Pediatric assessment. In: Prehospital Education for Prehospital Professionals, 3rd ed, Fuchs S, Klein BL. (Eds), Jones and Bartlett Learning, Burlington 2016. p.1.
- Gausche-Hill M, Henderson DP, Goodrich SM, et al. Assessment. In: Pediatric Airway Management for the Prehospital Professional, Gausche-Hill M, Henderson DP, Goodrich SM, et al (Eds), Jones and Bartlett, Sudbury 2004. p.13.
- Young KD, Korotzer NC. Weight Estimation Methods in Children: A Systematic Review. Ann Emerg Med 2016; 68:441.
- Wells M, Goldstein LN, Bentley A. It is time to abandon age-based emergency weight estimation in children! A failed validation of 20 different age-based formulas. Resuscitation 2017; 116:73.
- DuBois D, Baldwin S, King WD. Accuracy of weight estimation methods for children. Pediatr Emerg Care 2007; 23:227.
- So TY, Farrington E, Absher RK. Evaluation of the accuracy of different methods used to estimate weights in the pediatric population. Pediatrics 2009; 123:e1045.
- Sinha M, Lezine MW, Frechette A, Foster KN. Weighing the pediatric patient during trauma resuscitation and its concordance with estimated weight using Broselow Luten Emergency Tape. Pediatr Emerg Care 2012; 28:544.
- Heyming T, Bosson N, Kurobe A, et al. Accuracy of paramedic Broselow tape use in the prehospital setting. Prehosp Emerg Care 2012; 16:374.
- Fuchs S, Terry M, Adelgais K, et al. Definitions and Assessment Approaches for Emergency Medical Services for Children. Pediatrics 2016; 138.
- Wells M, Coovadia A, Kramer E, Goldstein L. The PAWPER tape: A new concept tape-based device that increases the accuracy of weight estimation in children through the inclusion of a modifier based on body habitus. Resuscitation 2013; 84:227.
- Mace, SE. End-tidal CO2 monitoring: Noninvasive respiratory monitoring for the child in the ED. Pediatric Emergency Medicine Reports 2006; 11:13.
- Berkenbosch JW, Lam J, Burd RS, Tobias JD. Noninvasive monitoring of carbon dioxide during mechanical ventilation in older children: end-tidal versus transcutaneous techniques. Anesth Analg 2001; 92:1427.
- Abramo TJ, Wiebe RA, Scott SM, et al. Noninvasive capnometry in a pediatric population with respiratory emergencies. Pediatr Emerg Care 1996; 12:252.
- Tobias JD, Meyer DJ. Noninvasive monitoring of carbon dioxide during respiratory failure in toddlers and infants: end-tidal versus transcutaneous carbon dioxide. Anesth Analg 1997; 85:55.
- Burton JH, Harrah JD, Germann CA, Dillon DC. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices? Acad Emerg Med 2006; 13:500.
- DeNicola LK, Kissoon N, Abram HS Jr, et al. Noninvasive monitoring in the pediatric intensive care unit. Pediatr Clin North Am 2001; 48:573.
- Gennis PR, Skovron ML, Aronson ST, Gallagher EJ. The usefulness of peripheral venous blood in estimating acid-base status in acutely ill patients. Ann Emerg Med 1985; 14:845.
- Kirubakaran C, Gnananayagam JE, Sundaravalli EK. Comparison of blood gas values in arterial and venous blood. Indian J Pediatr 2003; 70:781.
- INITIAL ASSESSMENT
- Pediatric assessment triangle
- - Appearance
- - Work of breathing
- - Circulation to the skin
- Physical examination
- - Estimation of weight
- - Key assessments
- Ancillary studies
- - Pulse oximetry
- - End-tidal carbon dioxide measurement
- - Transcutaneous CO2 measurement
- - Arterial blood gas/venous blood gas
- INITIAL STABILIZATION
- Supplemental oxygen
- Assisted ventilation
- Circulatory support
- SUMMARY AND RECOMMENDATIONS