Anna K. Weiss, Frances B. Balamuth
Identifying the acutely ill child in the ambulatory setting is a challenge. Children presenting to pediatricians’ offices, urgent care practices, and emergency departments (EDs) may have a range of illnesses from simple viral infections to life-threatening emergencies. Although most children in this setting will have a benign course of illness, it is incumbent on the pediatric practitioner to quickly and accurately discern which children are likely to deteriorate from potentially serious or life-threatening disease. When assessing an acutely ill child, practitioners must remember that the early signs of severe illness may be subtle.
Assessment of vital signs is critical in all pediatric visits for acute illness, including temperature, heart rate, respiratory rate, and blood pressure. Normal vital signs vary with age. Although there have been increasing efforts to build evidence-based vital sign cutoffs for different age-groups, most institutions use nonempirically derived cutoffs such as those in Pediatric Advanced Life Support (PALS). Tachycardia is common in children presenting for acute care and can result from benign (fever, pain, dehydration) to life-threatening (septic shock, hemorrhage) conditions. An abnormal heart rate should prompt a full history and physical examination, as described later, and careful reassessment (often multiple times) after the presumed cause is identified and treated. The vast majority of children will improve after initiation of simple interventions such as antipyretics or analgesia. Tachycardia that persists after fever, pain, and dehydration have been treated must be evaluated further, particularly if the child appears ill or has deficit in perfusion or altered mental state.
Tachypnea is also common and has many causes, including fever, respiratory conditions (bronchiolitis, asthma, pneumonia), cardiac disease (e.g., heart failure), and metabolic acidosis (shock, poisoning, diabetic ketoacidosis). Similar to tachycardia, tachypnea often resolves with antipyretics in febrile children, and should be reassessed to ensure resolution once fever has been managed. In cases where bronchiolitis and asthma have been ruled out, persistent tachypnea and fever can be a sign of pneumonia, even in the absence of focal lung findings on examination. Consider evaluation for metabolic acidosis in cases of significant tachypnea without apparent pulmonary or cardiac causes. Apnea is a sign of respiratory failure and should be treated emergently with bag-valve-mask ventilation and immediate ED evaluation.
Hypotension is rare in children, and when present, it is a sign of critical illness. Children with hypotension should be evaluated in an ED. Hypotension is evidence of decompensated circulatory shock and can result from severe dehydration, sepsis, hemorrhage, neurogenic spinal shock, or cardiogenic shock.
Pulse oximetry (oxygen-hemoglobin saturation, SpO 2 ) should be assessed in children with respiratory or cardiac illness/compromise and also in children with underlying abnormalities of oxygenation. Healthy children have SpO 2 >95%. The practitioner should consider evaluating for any underlying respiratory or cardiac causes in children with SpO 2 <93–95%. For children with underlying abnormalities, the child's baseline SpO 2 should be assessed and alterations from that baseline should be investigated further.
The combination of bradycardia, hypertension, and altered breathing known as Cushing triad can be a sign of life-threatening increased intracranial pressure (ICP) and should be evaluated in an ED. Anisocoria and a 6th cranial nerve palsy are other signs of increased ICP. Toxidromes should also be considered in children with abnormal combinations of vital signs (see Chapter 77 ).
A thorough history is paramount to identifying patients whose condition will require prompt intervention. Obtaining an accurate history from young patients is challenging, particularly with preverbal or very anxious children who are unable or unwilling to localize the source of their discomfort. In such instances, parents or caretakers often provide the most important information, and their perceptions of the child's course of illness must be carefully considered. Pediatricians should be guided by the patient's chief complaint to ask open-ended questions that help distinguish between benign and potentially life-threatening disease entities. The most common complaints leading to acute care visits among children include fever, headache and altered mental status, trauma, abdominal pain and vomiting, respiratory distress, and chest pain. Table 80.1 describes signs and symptoms that should prompt immediate transfer to an ED or, if already in the ED, initiation of rapid intervention.
Table 80.1
History and Examination Findings That Should Prompt Immediate Intervention and/or Transfer to Emergency Department
| HISTORY AND EXAM FINDINGS | RISK FACTORS |
|---|---|
| RED FLAGS FOR RESPIRATORY FAILURE | |
| RED FLAGS FOR CIRCULATORY FAILURE | |
| RED FLAGS FOR NEUROLOGIC FAILURE | |
Adapted from Farah MM, Tay Y, Lavelle J. A general approach to ill and injured children. In Shaw KN, Bachur RG, editors: Fleischer and Ludwig's textbook of pediatric emergency medicine, Philadelphia, 2015, LWW.
Fever is the most common reason for a sick-child visit. Most cases of fever are the result of self-limited viral infection. However, pediatricians need to be aware of the age-dependent potential for serious bacterial infections, such as urinary tract infection (UTI), sepsis, meningitis, pneumonia, acute abdominal infection, and osteoarticular infection.
During the 1st 2 mo of life, the neonate is at risk for sepsis caused by pathogens that are uncommon in older children. These organisms include group B streptococcus, Escherichia coli , Listeria monocytogenes , and herpes simplex virus (HSV). In neonates, the history must include untreated maternal obstetric information and the patient's birth history. Risk factors for sepsis include untreated maternal group B streptococcus colonization, prematurity, chorioamnionitis, and prolonged rupture of membranes. If there is a maternal history of sexually transmitted infections (STIs) during the pregnancy, the differential diagnosis must be expanded to include those pathogens. Septic infants can present with lethargy, poor feeding, grunting respirations, and cool or mottled extremities, in addition to fever (or hypothermia). Febrile infants in the 1st 1-2 mo of life should be evaluated broadly for infection, including sampling blood, urine, and cerebrospinal fluid (CSF).
When the infant matures beyond 2 mo of age and receives their 1st set of vaccinations, serious bacterial infections become less common. Evaluation to rule out serious infection is an important part of treating the febrile older child. Children with fever should have a full set of vital signs, history, and physical examination to ensure that critical illness is absent and to identify any focal source. Red flags for septic shock include hypotension, poor perfusion, altered mental status, or the presence of purpuric or erythrodermic rash. Red flags for meningitis include severe headache, meningismus, and altered mental state. The presence of any of these signs should prompt emergency evaluation in the ED or rapid treatment if the patient is already in the ED.
Additional focal findings to consider include evaluation for acute otitis media, pharyngitis, pneumonia, abdominal infections (bacterial enteritis, appendicitis), skin and soft tissue infections, septic arthritis, and osteomyelitis. Occult UTI should be considered if 3 of the following risk factors are present: age <1 yr, fever >39°C, fever >48 hr, and no focal source of fever. Pneumonia should be considered in the presence of tachypnea, hypoxia, or focal findings on chest examination. Bacteremia is rare in the post–pneumococcal and Haemophilus influenzae vaccine era but should be considered if staphylococcal infection or meningococcemia is suspected, as well as in unvaccinated children or children with signs of septic shock. In addition to infection, inflammatory conditions to consider include juvenile idiopathic arthritis and Kawasaki disease. The diagnosis of Kawasaki disease should be considered if the patient meets the diagnostic criteria for this illness although some patients may have an atypical or incomplete presentation (see Chapter 191 ).
For patients presenting in an altered mental state , the pediatrician should inquire about any symptoms, such as fever or headache. Screening questions should explore feeding changes, medications in the household, ill contacts, and the possibility of trauma. Parents will often describe a febrile child as lethargic, but further questioning will reveal a tired-appearing child who interacts appropriately when no longer febrile. The child who appears ill only when febrile must be differentiated from the lethargic patient who presents with suspected sepsis or meningitis, and from the child whose altered behavior is secondary to an intracranial emergency or seizure. Infants with meningitis, sepsis, or cardiac defects may have a history of irritability, being inconsolable, poor feeders, grunting breathing, seizures, poor urine output, and/or color changes such as pallor, mottling, or cyanosis. Patients with poisoning or inborn error of metabolism can also present with lethargy, poor feeding, unusual odors, seizures, and vomiting. Nonaccidental trauma should always be considered in a lethargic infant, particularly in the absence of additional signs or symptoms. In infants and young toddlers, rapidly growing head circumference or bulging anterior fontanel may signal increased ICP. Older children may present with altered mental state as a result of meningitis/encephalitis, trauma, or ingestions. School-age children and adolescents with meningitis may have a history of fever and neck pain; other associated symptoms may include rash, headache, photophobia, or vomiting. Children with ingestions can present with other abnormal neurologic symptoms, such as ataxia, slurred speech, and seizures, or with characteristic constellations of vital sign changes and other physical findings consistent with certain toxidromes.
In patients with headache , ask questions about the chronicity of the headache and any accompanying symptoms. Headaches that occur on arising in the morning, are worse when lying flat, or are accompanied by vomiting are concerning for increased ICP. Similarly, headache accompanied by focal neurologic deficit should be referred to an ED for urgent head imaging. While migraine headaches in teenagers are similar in presentation to those in adults (unilateral, throbbing, accompanied by an aura), pediatric practitioners should be aware that migraines in prepubertal children may have a nonclassic presentation and may be bilateral and not accompanied by aura, photophobia, or phonophobia.
Parents may interpret a variety of symptoms as respiratory distress , and care must be taken to distinguish normal and benign respiratory patterns from true respiratory distress. Tachypnea secondary to fever is a common source of parental anxiety, and parents of newborn infants are sometimes alarmed by the presence of periodic breathing. Parents should be questioned about their child's other symptoms, such as fever, limitation of neck movement, drooling, choking, and the presence of stridor or wheezing. A history of apnea or cyanosis warrants further investigation. Practitioners should also remember that tachypnea in a child without evidence of true respiratory distress may be evidence of compensation for shock or metabolic acidosis, both of which will require rapid treatment. Although wheezing is often secondary to bronchospasm, it can also be caused by cardiac disease or congenital airway anomalies such as vascular rings. Parents may interpret true stridor as noisy breathing or wheezing. Stridor is most frequently caused by upper airway obstruction such as croup. However, anatomic abnormalities such as laryngeal webs, laryngomalacia, subglottic stenosis, and paralyzed vocal cords also cause stridor. Toddlers who present with breathing difficulty after a coughing or choking episode should be evaluated for foreign body aspiration . In these cases, practitioners must ask about the possibility of button-battery ingestion, as this constitutes a true medical emergency that warrants immediate endoscopic removal or transfer to a facility that can perform the procedure. In toxic-appearing children with stridor, the pediatrician should consider epiglottitis, bacterial tracheitis, or a rapidly expanding retropharyngeal abscess. The incidence of epiglottitis has greatly declined with the advent of the H. influenzae type b (Hib) vaccine, but it remains a possibility in the unimmunized or partially immunized patient. Children with retropharyngeal abscesses may also present with drooling and limitation of neck movement (especially hyperextension) after a recent upper respiratory infection or penetrating mouth injury.
Abdominal pain is a very common complaint in the ambulatory setting and can herald either acute intraabdominal or pelvic pathology, or it can be a subtler sign of systemic illness. Both relatively benign (e.g., streptococcal infection, UTI, pneumonia) and severe abdominal (e.g., appendicitis) or systemic (e.g., diabetic ketoacidosis) illness can present with abdominal pain, and questions to the patient and parent should include whether there is an extraabdominal source of discomfort. Questions should include details about pain onset and location; presence of accompanying symptoms, such as fever, abdominal distention; and changes in feeding, urination, and stooling patterns. Care should be taken to elicit a history of peritonitis or obstruction, including worsening pain with abrupt movements and persistent or bilious vomiting.
In neonates, a tender abdomen with or without bilious emesis should raise concern for the presence of a small bowel obstruction (volvulus). These infants appear ill and may have a history of decreased stooling. Pediatricians should be wary of neonates with abdominal tenderness and bloody stools, because 10% of cases of necrotizing enterocolitis occur in term infants. Infants with milk protein intolerance can also present with bloody stools, but these infants appear well and do not have abdominal tenderness. In older patients the differential diagnosis for emergency causes of abdominal pain expands to include intussusception and appendicitis. Patients with intussusception present in a variety of ways, ranging from colicky abdominal pain but otherwise well between episodes to being lethargic or in shock. The diagnosis of appendicitis in the child younger than 3 yr is extremely difficult because children in this age-group cannot localize pain well. In adolescent females with abdominal pain, practitioners must obtain a menstrual and sexual history, because acute lower abdominal pain may be caused by adnexal pathology, including ovarian torsion or ectopic pregnancy.
For patients with vomiting , pediatricians should ask if they have experienced bilious or blood-stained emesis, abdominal distention or constipation, weight changes, and diarrhea or bloody stools. An infant with bilious emesis and abdominal distention may have intestinal obstruction (as with midgut volvulus or Hirschsprung disease), whereas an infant who appears immediately hungry after nonbilious projectile vomiting may have pyloric stenosis. In an older child, vomiting may be caused by peritonitis or obstruction, as well as by systemic illnesses, including diabetic ketoacidosis, ingestion, or trauma. Patients with headache and vomiting raise the concern for increased ICP and should be questioned about neurologic changes, meningismus, and fever.
Practitioners should also obtain a thorough account of the child's past medical history . It is important to be aware of any underlying chronic problems that might predispose the child to recurring infections or a serious acute illness. Children with sickle cell anemia, indwelling central venous access devices, or immune compromise are at increased risk for bacteremia and sepsis. Similarly, children with prior surgery, including ventriculoperitoneal shunt placement or intraabdominal procedures, can develop complications from their previous surgeries.
Observation is important when evaluating the acutely ill child. Most observational data that the pediatrician gathers should focus on assessing the child's response to stimuli. Does the child awaken easily? Does the child smile and interact with the parent, or with the examiner? Evaluating these responses requires knowledge of normal child development and an understanding of the manner in which normal responses are elicited, depending on the child's age.
During the physical examination, the pediatric practitioner seeks evidence of illness. The portions of the exam that require the child to be most cooperative are completed first. Initially, it is best to seat the child on the parent's lap; the older child may be seated on the examination table. It is also important to assess the child's willingness to move, as well as ease of movement. It is reassuring to see the child moving about on the parent's lap with ease and without discomfort. Vital signs are often overlooked but are invaluable in assessing ill children. The presence of tachycardia out of proportion to fever and the presence of tachypnea and blood pressure abnormalities raise the suspicion for more serious illness. The respiratory evaluation includes determining respiratory rate, noting the presence or absence of hypoxia by SpO 2 , and noting any evidence of inspiratory stridor, expiratory wheezing, grunting, coughing, or increased work of breathing (e.g., retractions, nasal flaring, accessory muscle use). The skin should be carefully examined for rashes. Frequently, viral infections cause an exanthem, and many of these eruptions are diagnostic, such as the reticulated rash and slapped-cheek appearance of parvovirus infections and the stereotypical appearance of hand-foot-and-mouth disease caused by coxsackieviruses, as well as measles, chickenpox, and roseola. The skin examination may also yield evidence of more serious infections, including petechiae and purpura associated with bacteremia and erythroderma associated with a toxin-producing systemic infection. Cutaneous perfusion should be assessed by warmth and capillary refill time. The extremities may then be evaluated not only for ease of movement but also for the presence of swelling, warmth, tenderness, or alterations in perfusion. Such abnormalities may indicate focal infections (e.g., cellulitis, bone/joint infection) or vascular changes (e.g., arterial or venous thromboembolus).
When an infant is seated and is least perturbed, the examiner should assess the anterior fontanel to determine whether it is depressed, flat, or bulging. While the child is calm and cooperative, the eyes should be examined to identify features that might indicate an infectious or neurologic process. Often, viral infections result in watery discharge or redness of the bulbar conjunctivae. Bacterial infection, if superficial, results in purulent drainage; if the infection is more deep-seated, tenderness, swelling, and redness of the tissues surrounding the eye may be present, as well as proptosis, altered visual acuity, and impaired extraocular movement. Abnormalities in pupillary response or extraocular movements may also be indicators of cranial nerve abnormalities and if new, are indications for head imaging.
During this initial portion of the physical examination, when the child is most comfortable (and therefore most likely to be quiet), the heart and lungs are auscultated. It is important to assess the adequacy of air entry into the lungs, the equality of breath sounds, and any evidence of adventitial breath sounds, especially wheezes, rales, or rhonchi. The coarse sound of air moving through a congested nasal passage is frequently transmitted to the lungs. The examiner can become attuned to these coarse sounds by placing the stethoscope near the child's nose and then compensating for this sound as the chest is auscultated. The cardiac examination is next; findings such as pericardial friction rubs, loud murmurs, and distant heart sounds may indicate cardiac inflammation or infection. In the neonate, murmurs may herald congenital heart disease, especially in the presence of cyanosis, unequal extremity pulses, or a differential in upper- vs lower-extremity blood pressures. A complete cardiac exam should also look for displacement of the PMI (point of maximal impulse) and the presence of jugular venous distention or facial plethora.
The components of the physical examination that are more bothersome to the child are completed last. This is best done with the patient on the examination table. Initially, the neck is examined to assess for areas of swelling, redness, or tenderness, as may be seen in cervical adenitis. Resistance to neck movement should prompt evaluation for signs of meningeal irritation or retropharyngeal abscess. During examination of the abdomen , the diaper, if present, is removed. The abdomen is inspected for distention. Auscultation is performed to assess adequacy of bowel sounds, followed by palpation. Every attempt should be made to quiet a fussing child during this part of the exam; if this is not possible, practitioners should note that increased crying as the abdomen is palpated may indicate tenderness, especially if this finding is focally reproducible. In addition to focal tenderness, palpation may elicit involuntary guarding or rebound tenderness (including tenderness to percussion); these findings indicate peritoneal irritation, as seen in appendicitis. During palpation of the abdomen, practitioners should look for signs of hepatomegaly or splenomegaly. When palpating the bottom-most edge of the liver or spleen, examiners should begin in the pelvis and work upward toward the ribs, because severe organomegaly can be missed if the examiner begins palpating in the mid-abdomen. The inguinal area and genitals are then examined. One should assess the inguinal area for hernias. Care should be taken to examine the testicles of boys with abdominal pain; testicular trauma, testicular torsion, and epididymitis all may present with abdominal discomfort. A unilateral swollen or painful testicle with an absent cremasteric reflex on the affected side is concerning for testicular torsion and should be referred for emergent ultrasound and urologic consultation. After the genital exam, the child is then placed in the prone position, and abnormalities of the back are sought. The spine and costovertebral angle areas are percussed to elicit any tenderness; such findings may be indicative of vertebral osteomyelitis or diskitis and pyelonephritis, respectively.
Examining the ears and throat completes the physical examination. These are usually the most bothersome parts of the examination for the child, and parents frequently can be helpful in minimizing head movement. During the oropharyngeal examination, it is important to document the presence of enanthemas; these may be seen in many infectious processes, such as stomatitis caused by herpes or enteroviruses. This portion of the examination is also important in documenting inflammation or exudates on the tonsils, which may indicate viral or bacterial infection. Findings such as trismus or unilateral tonsillar swelling are concerning for peritonsillar abscess and for infections in the para- and retropharyngeal spaces; such cases should be referred for specialist ear, nose, and throat evaluation and imaging of the neck.
Repeating portions of the assessment may be indicated. If the child cried continuously during the initial clinical evaluation, the examiner may not be certain whether the crying was caused by the high fever, stranger anxiety, or pain, or is indicative of a serious or localizing illness. Constant crying also makes portions of the physical examination, such as auscultation of the chest, more difficult. Before a repeat assessment is performed, efforts to make the child as comfortable as possible are indicated. In young infants, persistent irritability , even when the examiner is absent from the room, is concerning for meningitis, encephalitis, or other causes of meningeal irritation (e.g., intracranial injury from nonaccidental trauma). When faced with a truly inconsolable infant, practitioners should have a low threshold to obtain head imaging and/or perform lumbar puncture, as the clinical scenario dictates.
Most patients who present to the pediatrician's office with an acute illness will not require acute stabilization. However, the pediatrician needs to be prepared to evaluate and begin resuscitation for the seriously ill or unstable child. Outpatient pediatric offices and urgent care facilities should be stocked with appropriate equipment necessary to stabilize an acutely ill child. Maintenance of that equipment and ongoing training of the office staff in its use is required, and every effort should be made to ensure that pediatric clinicians are PALS certified (see Chapter 81 ).
The evaluation of the potentially unstable child must begin with assessment of the ABCs—airway, breathing, and circulation. When assessing the airway , chest rise should be evaluated and evidence of increased work of breathing sought. The examiner should ensure that the trachea is midline and should listen carefully for evidence of air exchange at the level of the extrathoracic airway. If the airway is patent and no signs of obstruction are present, the patient is allowed to assume a position of comfort. If the child shows signs of airway obstruction, repositioning of the head with the chin-lift maneuver may alleviate the obstruction. An oral or nasal airway may be necessary in patients in whom airway patency cannot be maintained. These devices are not well tolerated in conscious patients because they may induce gagging or vomiting; instead, they are most often used to facilitate effective bag-valve-mask ventilation in semiconscious or unconscious children. Once airway patency has been established, the adequacy of breathing should be evaluated. Slow respiratory rates or cyanosis may signal impending respiratory failure. If the airway is patent but the child's respiratory effort is inadequate, positive pressure ventilation via bag-valve-mask support should be initiated. Oxygen should be administered to all seriously ill or hypoxic children via nasal cannula or face mask. Auscultation of the lung fields should assess for air entry, symmetry of breath sounds, and presence of adventitious breath sounds such as crackles or wheezes. Bronchodilator therapy can be initiated to alleviate bronchospasm. Racemic epinephrine is indicated for stridor at rest in a patient with croup. Once airway and breathing have been addressed, circulation must be evaluated. Symptoms of shock include tachycardia, cool extremities, delayed capillary refill time, mottled or pale skin, and effortless tachypnea. In children, hypotension is a late finding in shock and indicates that significant decompensation has already taken place. Vascular access is necessary for volume resuscitation in patients with impaired circulation, and an intraosseous line should be considered early if there is any difficulty in obtaining vascular access for a patient requiring resuscitation. Each time an intervention is performed, the clinician should reassess the patient to determine whether interventions have been successful and whether additional care is needed.
The majority of children evaluated in the office or urgent care setting for an acute illness can be managed as an outpatient . These patients should have a reassuring physical examination, stable vital signs, and an adequate follow-up plan before being sent home. A mildly dehydrated patient can be discharged home for a trial of oral rehydration. Patients with respiratory illness who exhibit signs of mild respiratory distress may be monitored at home, with a repeat examination scheduled the next day. Depending on the child's condition, the comfort of the parents, and the relationship of the family with the physician, telephone follow-up may be all that is necessary. When no specific diagnosis has been established at the first outpatient visit, a follow-up examination may yield the diagnosis and can provide reassurance for both the caregiver and the practitioner that a child's severity of illness has not progressed.
However, if it is deemed that the child needs a higher level of care, it is the pediatrician's responsibility to decide what method of transfer is appropriate. Physicians may be reluctant to call for help because of a misperception that emergency 911 services should be activated only for ongoing resuscitation. Emergency medical services (EMS) transport should be initiated for any child who is physiologically unstable (e.g., with severe respiratory distress, hypoxia, signs of shock, or altered mental state). If the family's ability to comply promptly with recommendation for ED evaluation is in question, this patient also should be transported by EMS. Some physicians and families may defer calling EMS because of the perception that a parent can reach the hospital faster by private motor vehicle. Although rapidity of transport should be considered, the need for further interventions during transport and the risk of clinical decompensation are other important factors in the decision to activate EMS. Ultimately, the legal responsibility for choosing an appropriate level of transport for a patient lies with the referring physician, until responsibility of care is officially transferred to another medical provider.