Primary Assessment – J-A-C-C-O-L-D

J-A-C-C-O-L-D is a quick visual and clinical screening tool during primary assessment in children: Jaundice, Anaemia, Cyanosis, Clubbing, Oedema, Lymphadenopathy, Dehydration.

J – Jaundice in Paediatric Patients

Clinical features:

• Yellow discoloration of sclerae and skin.
• Dark urine, pale or putty-coloured stools.

Associated symptoms:

• Fatigue, poor feeding or failure to thrive.
• Abdominal pain or hepatomegaly.
• Pruritus (especially in cholestatic disease).

Common causes (by age):

• Neonates: physiological jaundice, sepsis, haemolysis, biliary atresia.
• Infants/children: viral hepatitis, autoimmune or metabolic liver disease, haemolytic anaemias, biliary obstruction.

Key ED investigations:

• Liver function tests, conjugated vs unconjugated bilirubin.
• FBC, reticulocyte count, Coombs test if haemolysis suspected.
• Abdominal ultrasound if obstructive or structural disease suspected.

A – Anaemia in Paediatric Patients

Clinical features:

• Pallor (conjunctivae, palms, mucosa), tachycardia.
• Fatigue, irritability, poor feeding or exercise intolerance.

Common causes:

• Nutritional deficiencies – iron, folate, B12.
• Haemolysis – hereditary, autoimmune, infections.
• Chronic disease, renal disease, malignancy, blood loss.

Key ED investigations:

• Full blood count and blood film.
• Reticulocyte count, iron studies; consider haemolysis screen if indicated.
• Stool occult blood or other tests guided by history.

C – Cyanosis in Paediatric Patients

Clinical features:

• Bluish discoloration of lips, tongue, nail beds, or extremities.
• May be central (tongue) or peripheral (extremities).

Associated symptoms:

• Tachypnoea, respiratory distress.
• Irritability, poor feeding, lethargy.
• Failure to thrive, recurrent chest infections.

Important causes:

• Congenital heart disease (cyanotic lesions).
• Severe pneumonia, bronchiolitis, asthma, foreign body.
• Sepsis, shock, or methemoglobinaemia (rare).

Key ED investigations:

• Pulse oximetry and blood gas (consider co-oximetry if available).
• Chest X-ray, ECG; consider echocardiogram (often via cardiology).
• Basic bloods and lactate if septic or shocked.

C – Digital Clubbing in Paediatric Patients

Clinical features:

• Bulbous enlargement of distal phalanges, “drumstick” fingers.
• Loss of nail–fold angle, spongy nail beds.

Suggestive of chronic disease:

• Chronic suppurative lung disease (e.g., cystic fibrosis, bronchiectasis, TB).
• Cyanotic congenital heart disease.
• Chronic liver disease, inflammatory bowel disease, some malignancies.

Key ED considerations: clubbing is usually chronic – it should prompt you to look for long-standing cardiopulmonary or systemic illness and confirm appropriate follow-up.

O – Oedema in Paediatric Patients

Clinical features:

• Swelling of feet, ankles, legs, periorbital area or abdomen (ascites).
• Pitting oedema over bony prominences.

Common causes:

• Renal disease (e.g., nephrotic syndrome, nephritis).
• Cardiac failure, congenital heart disease.
• Liver disease, severe malnutrition, protein-losing enteropathy.

Key ED investigations:

• Urinalysis (protein, blood), U&E, creatinine.
• Liver function tests, albumin.
• Chest X-ray, echocardiogram where indicated.

L – Lymphadenopathy in Paediatric Patients

Clinical features:

• Enlarged lymph nodes (commonly cervical, axillary, inguinal).
• Nodes may be tender, mobile, or fixed depending on cause.

Common causes:

• Self-limiting viral or bacterial infections.
• Suppurative nodes, TB, atypical mycobacterial infection.
• Haematological malignancies or systemic inflammatory disease (less common but important).

Key ED considerations:

• Look for red flags – weight loss, night sweats, persistent fever, very large or hard, fixed nodes.
• Document size, site, tenderness, and overlying skin changes.

Suggested investigations: (guided by history)

• FBC, inflammatory markers, TB screening where appropriate.
• Ultrasound of node(s) if concern for abscess or malignancy.

D – Dehydration in Paediatric Patients

Key clinical signs:

• Dry mucous membranes, dry lips and tongue.
• Reduced tears, decreased urine output or dark urine.
• Sunken eyes, sunken fontanelle in infants.
• Tachycardia, cool peripheries, prolonged capillary refill in more severe cases.

Symptoms (depending on age and severity):

• Thirst, irritability, lethargy.
• Dizziness, weakness, headache in older children.
• Reduced activity, poor feeding.

Common causes:

• Gastroenteritis (vomiting and diarrhoea).
• Fever with poor intake, excessive sweating.
• Diabetes (e.g., new-onset diabetes or DKA), diuretics or other medications.

Clinical Grading (Bedside)

• Mild: Slightly dry mucosa, normal vitals, alert, urine output slightly reduced.
• Moderate: Dry mucosa, reduced skin turgor, sunken eyes/fontanelle, tachycardia, irritable.
• Severe: Very dry mucosa, markedly reduced turgor, deeply sunken eyes/fontanelle, weak rapid pulse, cold peripheries, lethargy or altered mental status.

Emergency Department Management

• Mild dehydration: Oral rehydration solution (ORS); small frequent amounts; continue feeding when possible.
• Moderate dehydration: ORS if tolerated; consider IV fluids if ongoing losses or inability to drink; monitor vitals and urine output closely.
• Severe dehydration / shock: Treat as an emergency – IV or IO access, isotonic fluid bolus (e.g. 10–20 mL/kg) over 10–20 minutes, then reassess and repeat as per local protocol.

Relevant investigations (based on severity and cause):

• U&E, creatinine, glucose, bicarbonate.
• Blood gas (venous/arterial) to assess acidosis and lactate.
• Urinalysis (ketones, specific gravity), stool studies if indicated.

Intravenous Rehydration – ED Approach

Choice of fluid:

• Isotonic crystalloids (e.g. 0.9% saline, Ringer’s lactate) are first-line in most children with significant dehydration or shock.
• Avoid hypotonic fluids for initial resuscitation.
• Use specialised protocols for DKA, hypernatraemia, or complex electrolyte disturbances.

Typical ED strategy:

• Start with a bolus of 10–20 mL/kg isotonic crystalloid over 10–20 minutes in shock; reassess after each bolus.
• Once circulation stabilised, calculate maintenance plus replacement according to local guidelines and ongoing losses.
• Monitor heart rate, blood pressure, capillary refill, mental status, urine output and weight (if possible).