Consultation

If the management recommended in these guidelines is not successful or if further guidance is required for on-going management, consult with the senior medical staff of the Emergency Department or Intensive Care Unit at the Royal Children's Hospital or the receiving hospital, with a view to further management during transport. RCH Emergency Department (03) 9345 6153 RCH Intensive Care Unit (03) 9345 5211 / 5212 / 5213 / 6555 AV Radios are installed in the RCH Emergency Department, Intensive Care and Neonatal Intensive Care Units to allow direct ambulance communications for consultation and notification of arrival. These departments can be accessed via the AV Metro Clinician. Rural Paramedics may also access this facility using their UHF Portable radios if in the MAS radio coverage area.

Perfusion Status Assessment
Editor's Note: You may also want to see the PSA Table that I compiled.
1	Normal Blood Volume Newborn approximately 80 ml/kg Infant and Child approximately 70 ml/kg
2	Definitions and Observations Same as for adults. Author's Notes i.e. Perfusion - Definition: The ability of the cardiovascular system to provide tissues with an adequate blood supply to meet their functional demands at that time and to effectively remove the associated metabolic waste products. Perfusion - Observations: - Skin: colour, temperature, moistness. - Pulse rate. - Blood pressure. - Conscious state.
3	Criteria a) Adequate Perfusion: Age Pulse Blood Pressure Newborn 120-160 N/A Infant 100-160 >70 mmHg systolic Small Child 80-120 >80 mmHg systolic Large Child 80-110 >90 mmHg systolic Skin - warm, pink, dry. Conscious, alert, active. b) Inadequate Perfusion: Age Pulse Blood Pressure Newborn <100/min or >170 N/A Infant <90/min or >170 <60 mmHg systolic Small Child <75/min or >130 <70 mmHg systolic Large Child <65/min or >100 <80 mmHg systolic Skin - cool, pale, clammy, peripheral cyanosis. Altered conscious state, restless. c) No Perfusion: Absence of palpable pulses. Skin - cool, pale. Unrecordable blood pressure. Unconscious

Respiratory Status Assessment
Editor's Note: You may also want to see the RSA Table that I complied.
1	Normal Respiratory Rates Newborn 40-60 breaths/min Infant 20-50 breaths/min Small Child 20-35 breaths/min Large Child 15-25 breaths/min
2	Definitions & Observations Same as for adults.
3	Criteria a) Signs of respiratory distress include: Tachypnoea Use of accessory muscles Grunting Pallor Wheezing Abdominal protrusion Chest wall retraction Cyanosis (late sign) b) Signs of hypoxia include: Infants Children Lethargy Restlessness Bradycardia Tachypnoea Hypotension Tachycardia Apnoea Cyanosis Pallor  Bradycardia (late sign)  c) Carbon dioxide retention manifestation is manifested by: - Sweating (uncommon in infants). - Tachycardia. - Bounding pulse. - Hypertension. . Pupillary dilatation. - Eventually leading to cardiovascular and central nervous system depression. Respiratory failure is common in the first two years of life. Small calibre airways are prone to obstruction. Respiratory distress may reflect disorder of other body systems - cardiac failure, abdominal distension, neurological problems.

Conscious State Assessment (Glasgow Coma Scale)

Child 4 years or less Child over 4 years Eye Opening Eye Opening Spontaneously 4 Spontaneously 4 React to speech 3 To voice 3 Reacts to pain 2 To pain 2 No response 1 No response 1 Best Verbal Response Best Verbal Response Appropriate words or social smile, fixes, follows 5 Orientated 5 Cries but consolable 4 Confused 4 Persistently irritable 3 Inappropriate words 3 Restless and agitated 2 Incomprehensible sounds 2 No response 1 No response 1 Best Motor Response Best Motor Response Spontaneous 6 Obeys command 6 Spontaneous Localises to pain 5 Localises to pain 5 Withdraws from pain 4 Withdraws from pain 4 Flexion response 3 Flexion response 3 Extension response 2 Extension response 2 No response 1 No response 1 Total Total

APGAR Scoring System

The APGAR score should be conducted 1 minute after delivery and repeated at 5 minutes after delivery. A score of: 7-10 Is considered satisfactory 4-6 Has moderate depression and may need respiratory support 0-3 Indicates a newborn requiring resuscitation Points 0 1 2 Appearance Blue, Pale Body pink Extremities blue Totally pink Pulse Absent <100 >100 Grimace None Grimaces Cries Activity Limp Flexion of Extremities Active motion Respiratory Effort Absent Slow and weak Good strong cry

Paediatric Pain Assessment

Paediatric pain assessment should be appropriate to the developmental level of the child. Pain can be communicated by words, expressions and behaviour such as crying, guarding a body part or grimacing. The QUESTT principles of pain (Baker and Wong, 1987) may be helpful in assessing paediatric pain. - Question the child. - Use pain rating scales. - Evaluate behaviour and physiological changes. - Secure parent's involvement. - Take cause of pain into account. - Take action and evaluate results. The following pain rating scales may be useful when assessing pain in children. FLACC Scale This is a behaviour scale that can be used for children less than three years of age or who are unable to communicate. Each of the five categories (Faces, Legs, Activity, Cry, Consolability) is scored from 0-2 and the scores are added to get a total from 0-10. Behavioural pain scores need to be considered within the context of the child's psychological status, anxiety and other environment factors. Points 0 1 2 Face No particular expression or smile. Occasional grimace or frown, withdrawn, disinterested. Frequent to constant frown, clenched jaw, quivering chin. Legs Normal position or relaxed. Uneasy, restless, tense. Kicking or legs drawn up. Activity Lying quietly, normal position, moves easily. Squirming, shifting back and forth, tense. Arched, rigid or jerking. Cry No cry (awake or asleep). Moans or whimpers, occasional complaints. Crying steadily, screams or sobs, frequent complaints. Consolability Content, relaxed. Reassured by occasional touching, hugging or "talking too", distractible. Difficult to console or comfort. The FLACC is a behaviour pain assessment scale which is © University of Michigan Health System and reproduced with permission for clinical use by Metropolitan Ambulance Service and Rural Ambulance Victoria. Wong-Baker FACES Pain Rating Scale This scale can be used with young children aged three years and older and may also be useful for adults and those from a non-English speaking background. Point to each face using the words to describe the pain intensity. Ask the child to choose face that best describes own pain and record the appropriate number. 0 2 4 6 8 10 No Hurt Hurts little bit Hurts little bit more Hurts even more Hurts whole lot Hurts worse From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission. Verbal Numerical Rating Scale This scale asks the patient to rate their pain from “no pain” (0) to “worst pain possible” (10) and is suitable for use in children over six years of age who have an understanding of the concepts of rank and order. Avoid using numbers on this scale to prevent the patient receiving cues. Some patients are unable to use this scale with only verbal instructions but may be able to look at a number scale and point to the number that describes the intensity of their pain.

Basic Life Support

Introduction Cardio-respiratory arrest in infants and children is most commonly caused by hypoxaemia, hypotension or both and should be suspected when the child or infant loses consciousness, appears pale or cyanosed or is apnoeic or pulseless. Examples of conditions causing cardiac arrest in infants and children are trauma, drowning, septicaemia, sudden infant death syndrome, asthma, upper airway obstruction and congenital abnormalities of the heart and lung. Infants and children most commonly arrest into severe bradycardia or asystole and this influences the order of resuscitative actions. However ventricular fibrillation is often encountered during the course of resuscitation due to congenital heart conditions or poisoning from cardioactive drugs. Respiratory arrest may occur alone but if treated promptly may not progress to cardio-respiratory arrest. The basic principles of paediatric life support are similar to those of adults. However, drug dosages are usually related to body weight and some procedures need to be adapted for differences in paediatric anatomy. Older children may be treated as per adult guidelines. Author's note: The sentence above, in italics, was used after consultation, to simplify the "original sentence", which was: Ventricular fibrillation may occur, however, associated with congenital heart conditions or secondary to poisoning to cardioactive drugs and is often encountered during the course of resuscitation. Airway To assess an airway in a newborn, infant or child, the positioning and techniques are similar to those for an adult with the exception that care should be taken to avoid over extension of the neck and head. Noisy breathing, stridor or wheeze and/or neck and chest soft tissue retraction on inspiration are signs of significant partial airway obstruction. To position the head and neck to maintain an open airway: Newborn & infants: Head and neck should be placed in the neutral position, avoiding additional neck flexion and head extension. Children: Use neck flexion and head extension with caution in the younger child. If necessary use chin lift or jaw thrust to clear the airway. The pharynx should be inspected with a laryngoscope and cleared of secretions using a Yankauer sucker. Magill forceps may be needed to remove a foreign body. Breathing If spontaneous ventilation is not present, an appropriate size oropharyngeal airway should be inserted and assisted ventilation should be commenced immediately using supplemental oxygen. Effective airway control and adequate ventilation with oxygen supplementation is the keystone of paediatric resuscitation. Circulation Commence external cardiac compression (ECC) if a pulse (carotid, brachial or femoral) is not palpable, or is less than 60 beats per minute (infants) or 40 per minute (children). Depth of Compression: Newborns, Infants and Children: Approximately one third the depth of the chest for all age groups. Approximately 50% of a compression cycle should be devoted to compression of the chest and 50% to relaxation. Method of Compression: Newborns and Infants: ECC for a newborn or infant can be performed with two fingers or by a two-thumb technique. In this latter technique, the hands encircle the chest and the thumbs compress the sternum. This is considered a more effective technique and is the preferred option for two-rescuers, however care should be taken to avoid restricting chest expansion during inspiration. The two-finger technique should be used by a single rescuer in order to minimize the transition time between ECC and ventilation. Child: Two handed technique as for adults. Ratios of Compressions to Ventilations: Newborn: Single rescuer: 3 compressions to 1 ventilation Two rescuers: 3 compressions to 1 ventilation Rate: Approximately 120 compressions per minute Infants and Children: Single rescuer: 30 compressions to 2 ventilations Two rescuers: 15 compressions to 2 ventilations Rate: Approximately 100 compressions per minute Ventilations via Bag-Valve-Mask should be delivered during a pause in chest compressions to allow adequate expansion of the lungs. Once intubated, interruption of chest compression for ventilation is not necessary as effective ventilation can be given against the resistance imposed by chest compression.