Primary Survey of a Paediatric Emergency Patient

The paediatric primary survey follows the ABCDE approach, but with awareness of the unique physiology and rapid decompensation seen in children.

• A – Airway with cervical spine consideration (if trauma).
• B – Breathing and ventilation.
• C – Circulation with haemorrhage control.
• D – Disability (neurological status).
• E – Exposure / Environment (undress to assess, then keep warm and safe).

Airway

A small, easily obstructed airway plus large tongue, big occiput and compliant chest wall make airway assessment and positioning critical in children.

Key clinical features of airway compromise:

• Stridor, gargling, snoring, silence (no air movement).
• Use of accessory muscles, suprasternal/intercostal/subcostal retractions.
• Inability to speak/cry normally, drooling, tripod posture.
• Altered mental status, agitation or lethargy.

Common causes:

• Foreign body, trauma, burns, anaphylaxis.
• Croup, epiglottitis, tonsillar abscess, severe asthma/bronchiolitis.

Immediate ED interventions (stepwise):

• Open airway: jaw thrust (if trauma) or chin lift; neutral position in infants (avoid hyperextension).
• Suction secretions; clear obvious foreign body if visible and safe.
• Use airway adjuncts if needed: oropharyngeal airway (OPA), nasopharyngeal airway (NPA) where appropriate.
• Provide high-flow oxygen; support with bag–valve–mask (BVM) if ventilation is inadequate.
• Call for senior help early if airway compromise persists or intubation is anticipated.

Airway Intubation in Paediatric Patients

Intubation is reserved for children with actual or impending airway failure. It is a high-risk procedure and ideally performed by experienced clinicians with appropriate backup.

Common indications:

• Actual or impending respiratory failure (despite optimal BVM/oxygen).
• Recurrent or prolonged apnea, severe head injury with poor GCS.
• Need to protect airway (coma, severe seizure, major trauma, risk of aspiration).
• Need for controlled ventilation (e.g. status asthmaticus, severe shock, raised ICP).

Preparation essentials:

• Choose correct ETT size and depth using local formulae or tape (e.g. Broselow).
• Have suction, BVM, backup airways and a “plan B” (e.g. supraglottic airway).
• Pre-oxygenate; consider RSI with appropriate drugs per paediatric protocol.
• Continuous monitoring: ECG, SpO₂, blood pressure, EtCO₂ if available.

Confirmation of tube placement:

• Continuous waveform capnography / EtCO₂ – gold standard in intubated patients with circulation.
• Bilateral chest rise, equal air entry, no gastric gurgling.
• Mist in tube, appropriate SpO₂ response.
• Chest X-ray to confirm depth and position (post-stabilisation).

Common causes of post-intubation desaturation:

• Dislodged or misplaced tube (oesophageal, right main bronchus).
• Obstruction (secretions, kinked tube, biting, equipment failure).
• Pneumothorax, aspiration, bronchospasm.
• Apnoea from over-sedation or inadequate ventilation.

Breathing

Respiratory distress is the most common cause of paediatric decompensation. Children can maintain blood pressure until late, so breathing issues must be recognised early.

Clinical features:

• Tachypnoea, nasal flaring, grunting, head bobbing.
• Intercostal, subcostal, and suprasternal recessions.
• Asymmetrical chest movement, decreased air entry, added sounds (wheeze, crackles, stridor).
• Cyanosis or low SpO₂ on pulse oximetry.

Common causes:

• Bronchiolitis, pneumonia, asthma, croup.
• Pneumothorax, pleural effusion, foreign body aspiration.
• Cardiac failure, sepsis with metabolic acidosis.

Key interventions:

• Position for comfort, minimise distress (e.g. sitting on caregiver’s lap).
• Provide oxygen (nasal cannula, face mask, HFNC as per local resources).
• Bronchodilators, steroids, nebulised adrenaline or other treatments per diagnosis.
• BVM support or NIV/ventilation if tiring, altered mental state or poor gases.
• Consider chest decompression if tension pneumothorax suspected.

Circulation

Children compensate with tachycardia and vasoconstriction; hypotension is a late and ominous sign. Assess early and repeat often.

Clinical features of poor perfusion:

• Tachycardia, weak or thready peripheral pulses.
• Prolonged capillary refill (> 2–3 seconds), cool peripheries, mottled skin.
• Altered mental status, decreased urine output.

Common causes:

• Hypovolaemia – dehydration, haemorrhage, burns.
• Distributive shock – sepsis, anaphylaxis.
• Cardiogenic shock – congenital heart disease, myocarditis, arrhythmias.

Key interventions (ED):

• Establish IV or IO access early; draw bloods as needed.
• Fluid resuscitation with isotonic crystalloid (e.g. 10–20 mL/kg bolus) in suspected hypovolaemia, reassessing after each bolus.
• Early antibiotics in suspected sepsis; treat arrhythmias per paediatric ALS algorithm.
• Escalate to inotropes/vasopressors in shock not responding to fluids; senior/ICU input essential.

Disability (Neurological Status)

A rapid neurological screen helps identify life-threatening brain or metabolic problems.

Primary tools:

• AVPU: Alert, responds to Voice, responds to Pain, Unresponsive.
• Paediatric Glasgow Coma Scale (pGCS) where possible.
• Pupil size and reactivity; limb movements and tone.

Red flag features:

• Reduced level of consciousness, seizures, focal neurological deficits.
• Persistent or severe headache, vomiting, bulging fontanelle in infants.
• Unequal pupils or abnormal posturing.

Common causes:

• Head injury, CNS infection (meningitis/encephalitis), raised ICP.
• Seizures, metabolic derangements (hypoglycaemia, electrolyte problems).
• Ingestions/poisonings, hypoxia, shock.

Key interventions:

• Check and correct blood glucose immediately.
• Treat seizures per status epilepticus protocol.
• Maintain airway and oxygenation; consider raised ICP precautions if suspected.
• Urgent imaging and senior input for head injury, focal deficits or suspected CNS infection.

Exposure / Environment

Fully examine the child while protecting them from cold, pain and distress. This is also where you pick up rashes, injuries and safeguarding concerns.

Key aspects:

• Undress the child appropriately to examine front and back; look for bruises, deformities, rashes, burns.
• Assess temperature – children lose heat quickly; use warm blankets, warmed fluids, radiant warmers if available.
• Look for signs of trauma, burns, bites, pressure marks or non-accidental injury patterns.

Common environmental issues:

• Hypothermia or hyperthermia.
• Burns (thermal, chemical, electrical), inhalational injuries.
• Neglect or unsafe living conditions (important to document and escalate appropriately).

Key interventions:

• Temperature management: keep warm (or cool appropriately in hyperthermia).
• Wound and burn care following local protocols; adequate analgesia.
• Safeguarding: involve senior staff and social services when non-accidental injury is suspected.