During the initial phase of resuscitation, monitoring vital signs and physiologic status is the key screening activity. Continuous monitoring with attention to changes may indicate response to
Able to be maintained independently Maintainable with positioning, suctioning Unmaintainable, requires assistance
Use of accessory muscles
Responsiveness (AVPU) Recognition of parents or caregivers Pupil size Posturing
AVPU, Alert, responds to voice, responds to pain, unresponsive.
therapy or further deterioration requiring additional intervention. During the initial rapid assessment, diagnostic evaluation often is limited to pulse oximetry and bedside measurement of glucose levels. The latter is important in any child with altered mental status or at risk for inadequate glycogen stores (infants, malnourished patients). After resuscitation measures, further diagnostic tests and imaging are often necessary.
The choice of appropriate diagnostic tests and imaging is determined by the mechanism of disease and results of evaluation after initial resuscitation. The initial evaluation of major
Central nervous Lethargy, agitation, delirium, obtundation, system
Respiratory Apnea, grunting, nasal flaring, dyspnea, retracting, tachypnea, poor air movement, stridor, wheezing
Cardiovascular Arrhythmia, bradycardia, tachycardia, weak pulses, poor capillary refill, hypotension
Skin and mucous Mottling, pallor, cyanosis, diaphoresis, poor membranes membrane turgor, dry mucous membranes *Action would seldom be taken if only one or two of these signs and symptoms were present, but the occurrence of several in concert foreshadows grave consequences. Intervention should be directed at the primary disorder.
trauma patients is focused on identifying evidence of hemorrhage and organ and tissue injury. For an acutely ill child with respiratory distress, a chest x-ray is important. Appropriate cultures should be obtained when sepsis is suspected. Children with historical or physical evidence of inadequate intra-vascular volume should have serum electrolyte levels obtained, including bicarbonate, blood urea nitrogen, and creatinine.
Resuscitation is focused on correcting identified abnormalities of oxygenation and perfusion and preventing further deterioration. Oxygen supplementation may improve oxygen saturation but may not completely correct tissue oxygenation. When oxygen supplementation is insufficient or air exchange is inadequate, assisted ventilation must be initiated. Inadequate perfusion is usually best managed initially by providing a fluid bolus. Isotonic crystalloids (normal saline, lactated Ringer solution) are the initial fluid of choice. A bolus of 10 to 20 mL/kg should be delivered in monitored conditions. Improvement, but not correction, after an initial bolus should prompt repeated boluses until circulation has been re-established. Because most children with shock have noncardiac causes, fluid administration of this magnitude is well tolerated. If hemorrhage is known or highly suspected, administration of packed red blood cells is appropriate. Monitoring for deteriorating physiologic status during fluid resuscitation (increase in heart rate, decrease in blood pressure) identifies children who may have decreased cardiac function. Fluid resuscitation increases preload, which may worsen pulmonary edema and cardiac function. If deterioration occurs, fluid administration should be interrupted, and resuscitation should be aimed at improving cardiac function.