ABCDE assessment and stabilisation of the acutely ill child — formative SAQs

1. First 60 seconds

"This infant is critically unwell with abnormal appearance, work of breathing and circulation to skin. I call the senior paediatric and resuscitation teams now, name a leader, allocate roles, and bring age- and weight-appropriate equipment and monitoring. I begin the hands-on primary survey immediately." The principle is recognise and call for help, then treat life threats as they are found; stabilisation precedes diagnosis. [9]

2. Age-adapted ABCDE stabilisation

A — Airway. Assess patency, position, abnormal sound or silence, secretions, and whether the infant can maintain and protect the airway. Position the airway, clear removable obstruction by suction, avoid agitating a threatened airway, and call airway expertise before failure. [9]

B — Breathing. Give high-flow oxygen initially because the infant is in failure; per the AHA 2020 guideline the previously healthy target is a saturation of 94 to 98%, using the lowest fraction that achieves at least 94%. Judge effective ventilation by chest rise, air entry, improving colour and interaction, not the monitor alone; I confirm a credible oximeter signal because oximetry does not measure ventilation. If breathing is ineffective I support it with a correctly sized bag and mask. [9]

C — Circulation. Diagnose shock from the whole picture (pulse rate and quality, skin colour and temperature, capillary refill with technique stated, blood pressure, mental state, urine output). Control obvious loss, gain access without repeated failed attempts, and give fluid in aliquots, stating the expected response before each and reassessing after each; the first-hour total is a ceiling, not a target. I stop for overload or no benefit, and I call for critical-care help early if vasoactive support may be needed. [3] [9]

D — Disability. Screen with AVPU; any response below Alert prompts a formal age-adapted Glasgow Coma Scale. Check bedside glucose now because feeding is reduced and the infant is unwell; I correct a dangerous low immediately through the local pathway and confirm when feasible without delaying treatment. [7] [9]

E — Exposure. Expose only what is needed, look for rash, injury and device problems, then cover and warm the infant; safeguarding documentation proceeds in parallel. [9]

3. The quieter infant

"A quieter chest after marked effort, with reduced air entry and reduced interaction, means respiratory muscle fatigue and impending failure, not improvement." I reassess effectiveness rather than rate alone. I support ventilation immediately, declare the improvement I expect, call airway or critical-care help, and reassess from A. Recovery requires easier breathing together with better air entry and improved interaction. [1] [9]

4. Reassessment, escalation and handover

After every action I return to A and check whether the expected change occurred; I record benefit, harm and unresolved threat, and I revise the differential from the trend. I escalate to senior, PICU or retrieval help as soon as the child may need support this service cannot provide, not after local options fail. The structured handover transfers identity and baseline, current physiology and trend, timed actions and response, the prioritised differential and pending tests, local limits, family and safeguarding information, and the next contingency and its owner. [8] [9]

1. Blood pressure does not exclude shock

Children compensate for circulatory failure by raising heart rate and vascular tone, so blood pressure is maintained until relatively late. This child already shows poor perfusion (mottling, weak pulses, prolonged refill, altered consciousness), which is decompensated shock in evolution; waiting for hypotension to diagnose shock is a classic and dangerous error. Shock is a whole-circulation diagnosis, never a single blood-pressure number. [3] [9]

2. Circulatory support and retrieval timing

I confirm shock from the integrated assessment, control obvious loss, and give fluid in aliquots (for example 10 to 20 mL/kg of crystalloid). Before each aliquot I state the expected response, and after each I reassess for benefit, no response or overload; the first-hour total is a ceiling, not a target. The Surviving Sepsis Campaign 2026 children's guideline supports up-front fluid with careful reassessment and attention to fluid balance. Because this hospital cannot provide paediatric intensive care or vasoactive agents, I call retrieval and critical care in parallel with resuscitation, before local support is exceeded, and I prepare escort, monitoring and a contingency for deterioration or transport delay. [3] [11]

3. The FEAST lesson

FEAST found increased early mortality with saline or albumin bolus compared with no bolus in African children with severe febrile illness. Its correct lesson is that a fluid algorithm cannot be transplanted across populations, shock types and available rescue resources. Here, in a well-resourced setting with a child in septic shock, I still give up-front aliquots, but I reassess rigorously after each, stop for overload or no benefit, and escalate to vasoactive support and retrieval rather than driving toward a fixed volume. [4]

4. Disability, weight estimation and the seizure trigger

I protect airway and breathing, time the seizure, and position the child safely. An ongoing convulsive seizure is status epilepticus and activates first-line benzodiazepine treatment at five minutes; I do not wait for two doses to fail, and I check and correct a dangerous low glucose immediately through the local pathway. For drug dosing, I use a measured weight if available immediately; otherwise I document a working weight from a recent reliable value, a credible caregiver estimate, or the trained length-and-habitus tool, and I use the local paediatric cognitive aid, re-weighing at the first safe opportunity. I then reassess from A and hand over the trend, timed treatments and response. [7] [9]