Chandler Assessment of the Sick Child

My first registrar post in Australia was in a mixed ED with children. The most common question I statement I encountered was

I’m not sure if this child needs to come into Hospital

I use the CHANDLER assessment tool to highlight potential red flags for paediatric admission. If 2 of the major groups are seen, the child should be strongly considered for admission and Paediatric specialist involvement.

CHANDLER

C – Colour

• Pale- perhaps dehydrated
• Blue- cyanosed, hypoxic, hypothermic
• Red- Rash, Burn, infection
• Pink- healthy

H – Hydration status

• Moderate dehydration (4-6% loss)
• Capillary refill time >2 secs
• Mild decreased skin turgor

• Severe dehydration(>7% loss)
• Capillary refill time >3secs
• Deep acidotic breathing
• Signs of shock (Tachycardia, Hypotension, altered mental state)
• Decreased skin turgor
• Sunken eyes

A – Alert

• GCS status
• Is the patient awake, smiling and interacting.
• With neonates are they looking around, interested in their surroundings- reaching out for things put in front of them or are they floppy and disinterested.
• For older children are they tired and miserable looking or hard to rouse.
• Is the child inconsolable

N – Nutritional Status

• Fat reserves
• Does the child have good nutritional reserve and appear to be on normal weight limits?
• Are they very underweight? Consider serious medical/surgical illness; anorexia or even neglect in the home?
• Is the child overweight? Consider weight related issues such as Diabetes.

D – Dysmorphia

• *Important to remember associations of certain conditions with particular syndromes
• Example – Congenital Heart Disease in children with Down’s Syndrome.
• These children can get sick very quickly.
• Children with syndromes also have an increased incidence of renal abnormalities and swallowing issues and at risk for aspiration

L – Limbs

• Are all the limb moving – particularly important in neonates or young toddlers with obvious communication issues.
• Take note of children not moving arms or legs, examining thoroughly for tenderness.
• Caution in those also with a limp.
• Problems may not be obviously in the knees or lower aspect of the leg but in the hip, or even in genitalia in boys.
• Consider Non-accidental injury also in children <2yrs

E – External Supports

• This can be noted on your first interaction with the child as parents or Ambulance bring them in.
• Does the child require external supports such as:
  • Wheelchair or splint. Does the parent carry them (when they can easily walk)
  • Oxygen, nebulisers or IV fluids
  • Sedation or significant analgesia prior to arrival
  • Cooling aids (wet towels/ ice packs etc)

R- Respiratory Distress

• Is the child’s breathing becoming compromised.
  • Increased Respiratory rate for age
  • Accessory Muscle use
  • Stridor
  • Posturing- tripod position
  • Sternal and Sub/intercostal recession
  • Tracheal Tug
  • Nasal Flaring and head bobbing

Additional Resources:

• Bakers Dozen B’s of Bashed baby badness
• RCH Clinical Guidelines – Dehydration
• PMH Clinical Guidelines