Home | Index | Next                           PEDIATRIC ASSESSMENT

INTRODUCTION 

Eleven percent of the EMS runs in Long Beach involve patients who are 14 years or younger.  Optimal patient care requires that the EMT-I and EMT-P understand the differences within the various pediatric age groups and be able to confidently identify and manage the critically ill child in the field.  The following topics will be discussed during this lesson:

            •           Anatomical Differences

            •           Physiological Differences

            •           Initial Assessment and Focused History and Physical Examination

            •           Pediatric Assessment Triangle

            •           Field Management

LESSON OBJECTIVES

At the end of this lesson the participants will be able to:

1.         State at least 4 important factors to consider when dealing with the pediatric patient.

2.         List the anatomical differences that can be found in the pediatric patient in regards to body proportions, airway, and musculoskeletal system.

3.         List the physiological differences that can be found in the pediatric patient.

4.         Describe how these anatomical and physiological differences can affect the management of these patients in the field.

5.         Discuss why it may be necessary to vary your approach to a pediatric patient based on their age.

6.                  Perform an initial assessment and focused history and physical examination on any pediatric age group.

7.         Explain how the Pediatric Assessment Triangle can help determine the severity of a child’s illness or injury and identify the potential physiologic problem.

8.         Identify normal ranges for pediatric vital signs.

9.         Identify the appropriate BLS field management that may be performed by EMS personnel.

KEY VOCABULARY

The following terms will be used during this lesson:

            •           EDAP - Emergency Department approved for pediatrics

            •           fontanel - membranous intervals at the angle of the cranial bones in infants; also known as "soft spot"

            •           obligate nose breathers - infants from birth to 2 months that do not know how    to breathe through their mouths yet

            •           obtunded - a reduced level of sensitivity and responsiveness

            •           PCCC - Pediatric Critical Care Center

            •           separation anxiety - fear of being separated from parents demonstrated by older            infants and toddlers

            •           stranger anxiety - fear of strangers appearing between eight and ten months of age

KEY CONCEPTS

The following section provides information and space for taking notes on the key concepts discussed by the instructor:

Pediatric Statistics

PERCENTAGE OF RUNS (by chief complaint)

            Trauma*                                   441      (51%)

            Seizures                                    86       (10%)

            Ingestion/Overdose                   16       (2%)

            Respiratory Distress                  32       (4%)

            Altered LOC                            12       (1%)

            Cardiac arrest                              3       (<1%)

            Other medical conditions           81       (9%)

            Coded as "OT"             195      (23%)                  

(LBFD Statistics: Jun to Aug 1995)

* Includes burns and drownings

DEALING WITH THE PEDIATRIC PATIENT

•           May feel like you are taking care of two patients when parent or guardian is present

•          Common responses of caregivers to a child’s acute illness or injury: disbelief, guilt, and anger

•           Children usually behave in a way consistent with how they truly feel

•           The child’s appearance is generally more important than the chief complaint; always look at the child and listen to the parent

•           Aggressive handling of the child can traumatize them psychologically

ANATOMICAL DIFFERENCES IN THE PEDIATRIC PATIENT

                  BODY PROPORTIONS

•           Head relatively larger than the rest of the body; proportions become adult-like by adolescence

•           Greater body surface area to total body weight than adult

PREHOSPITAL CONSIDERATIONS

During falls or mechanisms where the child is thrown, the body acts as a missile with the head leading the way; reason for high incidence of head trauma

Additional padding may be necessary under shoulders when maintaining airway or immobilizing the C-spine

Able to lose more body heat and water through the surface of the skin; prone to hypothermia and dehydration

AIRWAY

•           Tongue larger in comparison to size of the oral cavity

•           Trachea shorter and narrower; cartilage is more elastic and collapses easily

•           Younger children have a larger proportion of soft tissue in the airways

•           Newborns up to 2-4 months of life are obligate nose breathers

•           Airways smaller and narrower; narrowest part of airway is at the cricoid cartilage, unlike the adult which is at the level of the vocal cords

     PREHOSPITAL CONSIDERATIONS

Increased potential for airway obstruction

Vary technique with opening airway; head should be in a neutral position with neck slightly extended

Susceptible to swelling from edema and inflammation from foreign objects, allergic reactions, bacterial or viral infections

May have respiratory distress if nose congested or obstructed with mucous since unable to breath through mouth

Prone to obstruction when airways congested with fluid, mucous or secretions

                        MUSCULOSKELETAL

           Newborns have two fontanels; the anterior closes between 10 and 16 mos and the posterior closes between birth and 3 mos 

•           Thoracic cavity or chest wall is softer and more compliant

•           Weaker abdominal muscles cause appearance of abdomen to be distended; also liver and spleen lower and more anterior, so not as protected by the rib cage

•           Children are abdominal or diaphragmatic breathers until 8 years of age

     PREHOSPITAL CONSIDERATIONS

Assessment of the anterior fontanel can indicate dehydration or increased intracranial pressure

Rib fractures are uncommon; provides minimal protection to the underlying organs and blood vessels within this cavity. Chest trauma may appear subtle externally but have extremely detrimental internal injury

Provides minimal protection to the intra-abdominal organs; trauma to this area can lead to severe organ damage

Avoid any restriction or restraints over abdomen so that child may breathe easily; especially when packaging child for transport

PHYSIOLOGICAL DIFFERENCES

             PEDIATRIC DIFFERENCES

•           Metabolic rate higher than adults; they require more energy and consume more oxygen (illness and stress accelerates metabolic rate further)

•           Higher fluid requirements due to higher metabolic rates; newborn's total body weight is 70-80% water (adult only 50-60%)

•           Total circulating blood volume per unit of body weight greater than an adult by 25%; can be estimated to be 80-90 ml per kg

     PREHOSPITAL CONSIDERATIONS

Prone to hypoxia; provide high oxygen environment for critically ill or injured children

Prone to dehydration when there is increased fluid loss due to diarrhea, vomiting, or conditions that increase metabolic rate

With trauma, remember actual blood loss is relative to weight (e.g., 200 ml of blood loss may not affect an adult but can cause shock in a one year old)

GOLDEN RULE:

Varying your approach to the pediatric patient based on their age is one of the keys to a successful physical assessment.

GROWTH & DEVELOPMENT CHARACTERISTICS

INFANTS (BIRTH TO 6 MONTHS)

                     CHARACTERISTICS

                           APPROACH

•           Less than 2 months: Spend most of their               time sleeping or eating

•           Between 2 and 6 months: more active;                  constantly moving (extremities and head)              when fully alert

•           No stranger or separation anxiety yet

•           Strong or vigorous cry when healthy

•           Younger ones easily consoled with pacifier and older ones are easily distracted by light or repetitive noise

•           Relatively easy to assess; EMT or EMT-P can approach without concern that presence may upset child

•           Doesn't matter if exam done in parent's arms or not since there is no separation anxiety yet

•           Exam can proceed "head-to-toe" or "toe-to-head"

•           Save things that may scare them for last (i.e., stethoscope)

INFANTS (6 TO 12 MONTHS)

                     CHARACTERISTICS

                           APPROACH

•           Younger ones will demonstrate stranger anxiety; older ones will display separation anxiety

•           Despite appearance of alertness and understanding, has no capacity for rational understanding of events

•           Older children will mirror behavior they see around them; if care-taker hysterical, the child may act the same way

•           Can be difficult to assess; better to start with the “across the room” assessment and obtain history from a distance, before a hands-on exam so child does not perceive your presence as an immediate threat

•           Ask caregiver to assist during exam and treatment, only if they are calm and cooperative (e.g. they can hold stethoscope on chest, can hold oxygen mask, can raise up shirt so you can observe respiratory effort, etc.)

•           Stay low or at eye level with child; talk in a calm and reassuring manner

•           Have care-taker hold child in lap facing away from you, if possible, during exam

•           Exam should proceed "toe-to-head"

TODDLER (1 TO 3 YEARS)                                                  

                     CHARACTERISTICS

                           APPROACH

•          The “terrible two” stage actually begins at about 1 year and lasts until 3 years

•           Most toddlers resist logic, and they cannot be reasoned with.

•           Very mobile, opinionated and may be terrified of strangers

•           Very curious and have no sense of danger

•           Older toddlers may remember earlier                     experiences with doctors or nurses and                  be fearful about being examined

•           Approach the toddler slowly and keep physical contact to a  minimum until he/she is familiar with you

•           Stay low or at eye level with child; talk in a calm and reassuring manner

•           Allow toddler to remain with caregiver    

•           Use play or distraction to help with                       assessment; introduce equipment slowly                and encourage toddler to hold it

•           Give him/her limited choices; helps provide toddler with a sense of control

•           Exam should proceed “toe-to-head”

•           Ask caregiver to assist during exam and treatment

PRESCHOOLERS (3 TO 6 YEARS)

                     CHARACTERISTICS

                           APPROACH

•           Are magical and illogical thinkers; they aren’t always able to know the difference between fantasy and reality; they have many misconceptions about illness, injury, and bodily functions

•           Common fears for this age group include body mutilation, loss of control, death, darkness, and being left alone

•           Use simple terms to explain procedures; choose words carefully, using language that is age-appropriate

•           Allow child to handle equipment; elicit his/her help if appropriate

•           Set limits on behavior

•           Praise good behavior

•            Use games or distraction when necessary

•            Use dressings or bandages freely

SCHOOL-AGED CHILDREN (6 TO 12 YEARS)

                     CHARACTERISTICS

                           APPROACH

•           Talkative and analytical; able to understand the concept of cause and effect

•           May still have some wrong ideas about how their bodies work; by age 9, usually able to understand simple explanations about their bodies and like to be involved in their own care

•           May not always understand what it means to have a particular illness or injury

•           Common fears include separation from parents and friends, loss of control, pain, and physical disability

•           Often afraid to talk about their feelings and usually hide their thoughts; they may not be able to put their feelings into words

•           Speak directly to the child, then include the caregiver

•           Should be able to handle head-to-toe exams and can provide answers to simple history questions

•           Examiner should be calm, truthful, and provide simple explanation

•           Permit caregiver to stay with them as much as possible

•           Provide privacy and uncover areas only when necessary

ADOLESCENTS (12 TO 18 YEARS)

                     CHARACTERISTICS

                           APPROACH

•           May display great variability in their reactions to trauma and illness; they may be calm, mature and helpful or hysterical and uncooperative

•           May be overly modest or provocative

•           May provide reliable information or intentionally withhold or even falsify it

•           May take part in risk-taking behaviors; often feel that  they are “indestructible”

•           Fears permanent injury, disfigurement, or “being different” as a result of the illness or injury; may overreact to injuries that change their appearance no matter how simple

•           First attempt to approach patient as one would approach an adult

•           Be firm and avoid becoming angry if they are intentionally uncooperative

•           Watch for evidence of drug or alcohol abuse

•           Allow an EMS provider of the same sex to exam patient if the situation allows

•           Interview patient without parent, when possible, especially if they are hesitant to reveal complete details because of parents presence

•           Provide reassurance, when appropriate, regarding injuries affecting appearance or function

PEDIATRIC PATIENT ASSESSMENT

•        When assessing children, the Pediatric Assessment Triangle (PAT) should be added to the patient assessment sequence.

•        Although the general components of the patient assessment will remain that same as for the adult, modifications should be made for children.

•        When completing the detailed physical exam, it does not matter whether you proceed head-to-toe or toe-to-head, as long as all anatomical areas are included.

•        Do not delay the transport of critically ill or injured child in order to complete the focused history and detailed physical exam; if time allows, this can be performed en route to the hospital.

•        For critically ill/injured or unconscious children, follow the same patient assessment sequence as for the unconscious adult.

PEDIATRIC ASSESSMENT TRIANGLE (PAT)

•        Allows the EMT-I or EMT-P to develop a general impression of the child from across the room.

•       Assists in determining the level of severity, urgency for life support, and the key physiologic problems.

•       PAT can be completed in 30 to 60 seconds; the three components can be assessed in any order.

COMPONENTS OF PAT

Appearance

·         Reflects the adequacy of ventilation, oxygenation, brain perfusion, body homeostasis, and central nervous system function.

·         Assess from across the room; allow child to remain on caregiver’s lap.

·         Use bright lights or toys to measure interactiveness.

·         Have caregiver assist with assessment if appropriate

Characteristic:                    Features to look for:

Tone                                  Extremities should move spontaneously, with good muscle tone; should not be flaccid or move only to stimuli   

Interactiveness                    Should respond to environmental stimuli or presence of a stranger; should not be listless, obtunded or lethargic

Consolability                      Easily comforted or calmed by caretaker (i.e., speaking softly, holding child, or offering a pacifier)

Look/Gaze                         Should maintain eye contact with objects or people; should not have a “nobody home” or glassy-eyed stare

Speech/Cry                        Should be present, strong and spontaneous; should not be weak, muffled, or hoarse

GOLDEN RULE:

The child’s general appearance is the most important thing to consider when determining how severe the illness or injury is, the need for treatment, and the response to therapy.

Work of Breathing

·         Is a more accurate, quick indicator of oxygenation and ventilation than respiratory rate or chest sounds on auscultation.

·         Reflects the child’s attempt to make up for difficulties in oxygenation and ventilation.

Characteristic:                       Features to look for:

Abnormal airway sounds       Snoring muffled or hoarse speech, stridor, grunting, wheezing

Abnormal positioning            Sniffing position, tripoding, refusing to lie down

Retractions                            Supraclavicular, intercostal, or substernal retractions of the chest wall; head bobbing in infants

Flaring                                   Nasal flaring

Circulation to Skin

·        Reflects the adequacy of cardiac output and core perfusion, or perfusion of vital organs.

·        Cold room temperatures may cause false skin signs, i.e., the cold child may have normal core perfusion but abnormal circulation to the skin.

·        Inspect the skin (i.e., face, chest, abdomen) and mucous membranes (lips, mouth) for color in central areas.

·        In dark skinned children, the lips and mucous membranes are the best places to assess circulation.

Characteristic:             Features to look for:

Pallor                          White or pale skin or mucous membrane coloration

Mottling                      Patchy skin discoloration due to vasoconstriction

Cyanosis                     Bluish discoloration of skin and mucous membranes

INITIAL ASSESSMENT AND FOCUSED HISTORY AND DETAILED PHYSICAL

EXAMINATION OF THE PEDIATRIC PATIENT

INITIAL ASSESSMENT

1).  Assess environment:  May need to manipulate the environment

·        Safety of rescuers and environment

·        Environmental factors

Patient location (home, street, baby-sitter’s house, school)

Weapons, toys, objects (may indicate trauma mechanism)

Medications (may offer clues to past medical history)

Witnesses (may help to explain circumstances)

ADD PEDIATRIC ASSESSMENT TRIANGLE

Develop a General Impression: (the “across the room” assessment)

·        Assess appearance

·        Work of breathing

·        Circulation to skin

2).  Airway: (determine responsiveness and patency of airway)

·        Approaching an alert child too fast may cause crying and agitation, which interferes with assessment and may increase respiratory distress

·        Initiate spinal precautions if indicated

·        Introduce self to child

·        Obtain child’s name and age; use name throughout exam

·        Determine LOC in an age appropriate manner; may have to rely on caregiver

3).  Breathing: (assess rate, rhythm, and tidal volume)

·        Look at abdominal area for respiratory movement since they are abdominal breathers

·        If labored breathing, place the child on oxygen

4). Circulation:

a.       Palpate for pulse noting rate, rhythm and quality

·           Check the peripheral pulses (i.e., brachial or radial) for quality. If it is strong, the child is probably not hypotensive. If non-palpable, attempt to find a central pulse (i.e., femoral for infants and carotid for older children).

·           Compare peripheral and central pulses; discrepancies in quality of pulse can be due to cold air temperatures or decreased cardiac output.

b.      Assess capillary refill

·        Check capillary refill at the kneecap or forearm; normal refilling time is less than 2 to 3 seconds

·        Cold room temperatures can affect capillary refill

c.    Check for obvious bleeding; control if necessary   

5).  Skin signs:  (assess color, temperature and moisture)

·        Skin color has already been assessed with the PAT

·        With adequate perfusion, the child’s skin should be warm near the wrist and ankles

6).  Assess neurological status: (assess level of consciousness and neuro deficits)

     Complete Glasgow Coma Score: For the child

(L.A. County Reference #809)

Best Eye Opening Response:

            4          Spontaneous

            3          To voice

            2          To pain

            1          None

Best Motor Response:

            6          Obedient

            5          Localizes

            4          Withdrawal

            3          Flexion

            2          Extension

            1          None

Best Verbal response:

            5          Oriented

            4          Confused

            3          Inappropriate

            2          Incomprehensible

            1          None

Note: Child is considered to be age 12 months to 14 years; GCS has been found to be unreliable in infants but can be used as an estimation as appropriate.

7).  Determine chief complaint

These warrant immediate attention, despite appearance of child:

•   Fever in child < 3 months of age

•   Ingestion of toxic material

•   History of unconscious states or seizures

•   Potential anaphylaxis

•   History of  high impact trauma

•   Evidence of child abuse or sexual assault

FOCUSED HISTORY AND DETAILED PHYSICAL EXAMINATION

1).  Elicit history of chief complaint or problem (PQRST)

·        Usually have to rely on caregiver for details of history; may ask child questions if age appropriate

·        Use PQRST if appropriate

2).  Elicit personal history (HAM)

·        H   medical history/under a doctor’s care

·        A    allergies/age

·        M   medications-current over the counter and prescription

3).  Vital Signs

·        May be unreliable indicator of the child's true condition

·        Can vary greatly with age, body temperature and anxiety

·        May be difficult to obtain due to constant motion, agitation and resistance of child

Blood Pressure:

·        Take only if appropriate size cuff available; width of cuff should be approximately 2/3 the length of arm between the shoulder and the elbow

·        Too difficult to obtain in children < 3 years old; however, should attempt on any child who is critically ill or injured

·        Hypotension is almost always a sign of late shock

·        Hypertension is uncommon; not a clinical problem for children in the field

Heart Rate:

·        For younger children and infants, heart rates are easier to obtain by palpating the brachial pulse or auscultating the apical pulse in the area of the left nipple

·        For older children, heart rates are obtained the same as adults

·        Take the rate for 15 seconds and multiply by 4; irregular rates may be taken for 30 seconds and multiplied by 2

·        Tachycardia is usually caused by hypoxia, fever, acute infection, anxiety, and can be an early sign of  shock

·        Fevers:  Each degree of fever raises the heart rate 8-10 beats/minute

·        Bradycardias can be due to critical hypoxia and/or ischemia

Respiratory Rate:

·        For children < 8 years old, observe abdominal movement for respiratory rates; alternative methods are placing your hand on the back or abdomen while counting rate or auscultating rate with a stethoscope (usually done at the same time that heart rate is being taken)

·        To obtain a respiratory rate, count the number of respiration for 30 seconds and multiply by 2

·        Hyperventilation may be due to hypoxia, fever, pain, anxiety or excitement

·        Fevers:  Each degree of fever raises the respiratory rate by 4 breaths/minute

·        Hypoventilation may be the result of drug overdose, severe head injury, exhaustion from labored breathing

PEDIATRIC VITAL SIGNS: NORMAL VALUES

 
Systolic Blood Pressure

70 mm Hg plus twice

the age in years

Age
Heart Rate

(beats/min)

Respiratory Rate

(breaths/min)

Infant

Toddler

Preschooler

School-aged child

Adolescent

100-160

90-150

80-140

70-120

60-100

30-60

24-40

22-34

18-30

12-16

CARDIAC MONITORING

·        EKG should be continuously monitored in children who have any respiratory or cardiovascular instability

·        A rhythm disturbance in a child should only be treated as an emergency if it compromises cardiac output or has the potential to degenerate into a lethal rhythm.

PEDIATRIC WEIGHT

·        Needed to calculate drug dosages or fluid challenges

·        Ask parents for actual weight, if known

·        Estimate - Use length-based measuring tape (Broselow)

4).  Special Questions

Ask caregiver or child questions specific to chief complaint

Examples:

·        Seizure – recent change in medication

·        SOB – last asthma attack

5).  Pertinent Body Check:

·        Medical or minor trauma - perform body check pertinent to chief complaint

·        Should complete a total body check whenever possible, even if complaint is minor

·        Use toe-to-head exams for infants, toddlers, and preschoolers

TOTAL BODY CHECK

Head-to-Toe or Toe-to-Head Examination:

The following areas warrant special mention:

Anterior Fontanel:

·        Should be assessed routinely in infants

·        Should be assessed with the infant sitting upright and not crying

·        A firm or bulging fontanel may indicate increased intracranial pressure; crying may also cause bulging

·        A sunken or depressed fontanel may be the result of dehydration

Breath sounds:

Because of the small size of the chest and lack of musculature, breath sounds in infants are easily transmitted throughout the chest. Auscultate breath sounds at the mid-axillary line bilaterally.

 Abdomen:

Optimal assessment is done when the child is quiet, lying down, and knees bent; distracting the child may be necessary since he/she may tense their abdominal muscles if they anticipate your approach.

General Inspection:

·        Look for any bruises, hematomas, abrasions, lacerations, fractures, unusual markings, etc.; be alert to any injuries that cannot be explained or is inappropriately explained, or not possible due to the age of the child.

·        Observe skin for rashes, especially accompanied by fevers

·        Signs of dehydration

GOLDEN RULE:

The physiologic status of the child can change very quickly, so repeated

assessments are necessary.

FIELD MANAGEMENT – BLS CARE

                         PROCEDURE

•           Oxygen therapy - Administer oxygen for any child in respiratory distress or shock, or who is seriously ill/injured

            Mask: Flow rate 6 - 10 L/min

            Nasal cannula: Flow rate < 4L/min

•           Assisted ventilation -  must be provided if spontaneous ventilation is inadequate, or if apnea, gasping, or persistent cyanosis despite oxygen is present

            Flow rate 10 - 15 L/min

•           Position of comfort

                        TECHNIQUES                      

Various methods: nasal cannula with prongs cut away, mask to face if tolerated, or some method of  "blow-by" oxygen

May be beneficial to remove oxygen if condition worsens due to agitation.

Use appropriate size bag-valve device; should provide effective chest expansion.

Should be attempted even in the presence of airway obstruction.

Should be coordinated with child's breaths, if present, to avoid coughing, vomiting, laryngospasm, and gastric distension.

In unconscious patients, gastric inflation and regurgitation can be minimized by applying cricoid pressure during assisted ventilation.

Oxygen-powered breathing devices are not recommended for pediatrics.

Allow patient to choose (i.e., parent's lap, leaning forward, knee-chest); forcing the patient may worsen condition.

TREATMENT OF MINORS  (Reference #832)

•           In the absence of a parent or legal guardian, minors with an emergency condition can be treated by EMS providers and transported to the most appropriate facility.

•           If EMS providers believe a parent or other legal guardian of a minor is making a decision which appears to be endangering the health and welfare of the minor by refusing immediate care or transport, law enforcement authorities should be involved.

•           Minors who are evaluated by EMS providers and determined not be injured, to have sustained only minor injuries, or to have illnesses or injuries not requiring immediate treatment or transport, may be released to: self, parent or legal guardian, a responsible adult on scene, designated care giver, or law enforcement. (Document on EMS Report to whom patient was released.)

Home | Index | Next