The Quick and Dirty Guide to Pediatric

Assessment

Although children account for only a small percentage of pre-hospital

emergencies, they present a special challenge to EMS professionals;
both patient and crew suffer extreme emotional stress and anxiety, in
many cases. They aren't mini-adults, so their anatomy and physiology
including airway, breathing, circulation, muscle, and skeleton system
deserve special consideration, since they grossly differ from an adult.
The internal organs are in closer proximity and more tightly encased to
each other in children than in adults, and this places children at higher
risk of traumatic injury due to the "tight quarters". The reaction to
pain/illness and the capabilities to deal with it, in children is different
depending on their developmental stages.

Developmental Stages
Infants: 1-12 months - Between 4-6 months most infants have
doubled their birth weight; tripling it by the 12 months. In the first
year, infants can usually walk and their heart doubles in size, the
heart rate slows, and BP starts to increase. Common illnesses will
typically affect the respiratory, GI, and CNS, manifesting as:
- Respiratory distress
- Nausea
- Vomiting
- Dehydration
- Seizures
- Meningitis
- SIDS
Toddlers: 1-3 years - Muscle Mass and bone density increases
during the toddler stage, normally gaining 2 kg (5 lbs) each year. By
age 2 the nervous system is fully developed and functioning. Most
are able to control voluntary control of urinary/bowel movements.
Basic language skills normally develop by age 3. They begin to
notice the difference in male and female. The common illnesses
that affect toddlers:
- Respiratory distress
- Asthma
- Bronchiolitis
- Croup
- Nausea
- Vomiting
- Diarrhea
- Dehydration
- Febrile seizure
- Sepsis
- Meningitis
Pre-school age: 4-5 years - During the preschool years, children
experience advances in gross and fine motor skills. Illnesses are
similar to the conditions mentioned for 1-3 year old but, this age
group is more likely to get into trouble. This trouble includes falls,
burns, lacerations, and accidental poisonings. Preschoolers are
curious and have an urge to explore, but they have no concept of
danger until it is too late.
School age: 6-12 years - The growth of school-aged children is
slower and more steady than seen with preschoolers. Most children
at this age gain over 3 lbs. and grows 2.5 inches per year. Most
illnesses are viral and injuries are more common because of their
increased independence and activity.
Adolescent: 13-18 years - During adolescence, the final stage of
change in growth and development occurs. Organs rapidly increase
in size and blood chemistry is similar to an adult.
Anatomy and Physiology Review

Head
The biggest thing to keep in mind when treating a child is that the
differences in infants and children set them apart from the adult patient
so, often a review of the anatomy is recommended. A child's head is
proportionately larger than adults, accounting for 25% of the total body
weight, in newborns especially. Children have a larger occipital region
and a face that is smaller compared with the total size of the head.
Because of this relative size difference, a high percentage of trauma in
children involves the head and face.
When using spinal immobilization for a child <3 years old, it may be
indicated to place a small padding under the patient's shoulders to
maintain a natural, neutral alignment. A folded sheet placed under the
occiput of a severely ill child >3 years old or under the shoulders if the
child is <3 years old, can help to establish a sniffing position needed to
maintain an adequate airway.
To accommodate for the normal growth of the brain of an infant, the
anterior fontanelle remains open and vulnerable to injury for 9 to 18
months after birth. The anterior fontanelle is usually level or slightly
below the surface of the skull. A bulging or tight fontanelle indicates
possible increased ICP. A sunken fontanelle that is sunken, it suggests
dehydration in the infant. EMS professionals should assess the anterior
fontanelle in infants and young children who are ill or injured. This is best
assessed in an upright sitting position when the child is calm and not
crying.

Airway
The airway structures of children are narrower and way less stable than
an adult's. This naturally makes the airway more vulnerable to
obstruction from secretions, obstruction, or inflammation. In addition, the
larynx is higher (at the level of C3-C4), more anterior, extending into the
pharynx. The tracheal cartilage is smaller in length/diameter and is
bifurcated at a higher level than in adults. The cricoid cartilage is the
narrowest part of a young child's airway. Proportionately the jaw is
smaller and the tongue is larger, increasing the likelihood of an
obstruction by the tongue in an unconscious child. The epiglottis is
omega-shaped and extends into the airway at a 45* angle. The epiglottic
folds are softer and become "floppy", also causing obstruction. Avoid
hyperflexion or hyperextension of the patient's neck to avoid airway
occlusion. It may be indicated to modify tracheal intubation techniques
to ensure a gentle touch on the soft tissues of the trachea, which is very
easily injured. Using a straight blade that lifts the epiglottis, choosing an
appropriate sized ET tube, and constantly monitor the airway for proper
tube placement.

Note: Infants for the first month or so of life are mainly nose breathers.
Mucus and secretions in the nares may be enough to cause significant

obstruction.
Don't miss this intubation of an infant at a NREMT
exam station!
Chest and Lungs

In infants and young children, the chief support for the chest wall comes
from immature muscles that are easily fatigued, rather than bones. The
use of these muscles for breathing also requires a higher metabolic and
O2 consumption rate than older children and adults, causing a build-up
of lactic acid in the child's blood. The ribs of a child are more pliable and
are positioned horizontally, and the mediastinum is more mobile, offering
less chest wall protection to the internal organs within the chest cavity.
The lung tissue of children is very fragile, because of this and the limited
protection offered by the developing rib cage, pulmonary contusions
from trauma and pneumothorax from barotrauma are common in this
age group. The thin chest wall allows for easily auscultated breath
sounds, which makes assessing adequate breath sounds and confirming
ET tube placement difficult in the field. It is a good idea to assess the
axillary regions as well as, the anterior and posterior locations in these
patients.

Note: When evaluating a pediatric patient that sustained serious trauma,

it is important to remember that infants and children are diaphragmatic
breathers, which means gastric distention is common.

Abdomen
Like the chest wall, the immature muscles of the abdominal region,
offers little protection to the already tightly encased organs within the
abdomen.The liver and spleen are proportionately larger and more
vascular than adults. This leads to the possibility of multiple organs
being injured in the event of significant abdominal trauma.

Extremities
Bones in children are softer and more porous until they reach
adolescence. As long bones mature, hormones act on the cartilage,
replacing the (softer) cartilage with (harder) bone. The epiphyseal plate
(growth plate) lengthens as the bones develop; becoming thicker as new
layers are added over old layers. Because of the potential for fracture
any sprains, strains, and bone contusions should be treated as if it were
a complete fracture. They should be manged with full extremity
immobilization and PMS reassessment often. In addition, paramedics
must use extreme caution when inserting an IO needle. Improper
insertion can cause growth problems for the child for years to come.

Skin
The skin of children is thinner yet more elastic than adults and has less
SQ fat. A child has a larger body surface area to body mass ratio. These
factors should be considered when an injury occurs or environmental
factors are present (Cold-hypothermia; Hot-Hyperthermia; Sun-Sunburn).

Respiratory System
The tidal volume of infants and young children is much less than that of
adolescents and adults, but the metabolic requirements for normal
breathing are about double, with a smaller residual capacity. Because of
these factors hypoxia can and will rapidly develop.

Note: The muscles support the chest wall and tire easily in times of
distress, so respiratory may develop quickly.
Cardiovascular System
Cardiac output is rate dependent in infants and young children; meaning
the faster the heart rate, the greater the cardiac output. These patients
are not able to increase contractibilty or stroke volume. The circulating
blood volume is proportionately larger than adults, yet the overall
absolute blood volume is less. The ability to vasoconstrict the vessels
helps maintain a viable BP much longer than adults. Hypotension is a
very late sign of shock in a pediatric patient. Therefore, the assessment
of shock must be based on the clinical signs of adequate tissue perfusion
(i.e., LOC, skin color, cap refill). However, early intervention is required to
prevent irreversible or decompensated shock. Special consideration
include:

The pediatric cardiovascular reserve is vigorous but, limited

The loss of a small amount of blood/fluid can cause shock
A child may hide the signs of shock and may be in shock with
normal vitals
Bradycardia is often caused by hypoxia

Note: EMS personnel should suspect shock in any ill/injured child that has
tachycardia and evidence of decreased tissue perfusion.

Nervous System
The neural tissue is fragile; nervous system develops throughout
childhood. In addition, the anterior and posterior fontanelles remain open
for a period of time. Therefore, head injuries involving TBI can be
devastating to the infant or young child. The child does have the
advantage of superior brain and spinal cord protection from the spinal
column and skull.
Metabolic Differences
The way in which children and adults expend energy are different in
many ways. For example, infants/children have limited glycogen and
glucose stored. Their blood glucose levels can drop dramatically in
response to illness/injury, with or without a history of diabetes mellitus.
Pediatric patients can lose a significant amount of fluid from vomiting
and diarrhea, making them very prone to dehydration. Because of the
increased skin surface area, the pediatric patient is susceptible to
hypothermia/hyperthermia. For all these reasons it is important to assess
the blood sugar levels and prevent hypothermia by keeping them warm,
in all ill/injured children.

General Pediatric Assessment

The initial assessment of a child should include looking at the
patient and involving the parents in the process. This helps keep
them calm and makes the patient more comfortable with the
assessment. The parent can offer valuable information that may
become vital in the child's treatment. Parents are also the best
way to assess the normal mannerisms of the child.

Initial Assessment
The initial assessment begins with the EMS professional forming a
general impression of the patient. The assessment should focus on the
details most valuable to the situation, to determine whether a life threat
exists. The pediatric assessment triangle is a paradigm that can be used
to quickly assess a child (as well as adults, but thats another story for
another day) and the potential for immediate interventions. The triangle
has 3 components:

1.Appearance of mental status and muscle tone

2.Work of breathing including rate and effort
3.Circulation; assessing skin color/condition

Note: If the child's condition is urgent, focus on the basics (Circulation,

Airway, Breathing), stabilization and transporting rapidly but, safely!

Vital Function
The AVPU scale which assesses, alertness, patients response to verbal
stimuli, painful stimuli, or unresponsive or the modified Glasgow coma
scale. For details on the pediatric Glasgow coma scale check
out Glasgow Coma Scale Made Easy!
Airway & Breathing
The child's airway must be patent, and breathing should proceed with
adequate chest wall rise and fall. Signs and Symptoms of respiratory
distress include the following:

Abnormal/absent breath sounds

Bradypnea/Tachypnea
Grunting
Head bobbing
Irregular patterns to respiration
Nasal flaring
Accessory muscle usage

Circulation
Assess the pediatric circulation by comparing the strength and quality of
central and peripheral pulses, measuring BP (mainly pts >3), evaluating
skin color, temperature, cap. refill, and skin turgor. Assess for the
presence of life-threatening hemorrhage and control it.
Focused History
The transition phase is used to allow the child to become more familiar
with the crew and equipment, by having conversations and allowing
them to touch and play with things that won't hurt them; i.e.,
stethoscope. This is only appropriate if the patient is conscious, alert,
and not critical. If the patient is critical or unconscious; all interventions
should be accomplished while providing a rapid, safe transport to an
appropriate facility.
Obtaining a history on an infant, toddler, or preschooler, is nearly
impossible. The EMT must obtain reliable information from the
caregiver/parent. School-aged adolescents can answer and provide most
of the needed information by themselves. The focused history on a
pediatric patient can be obtained by using age appropriate parts of the
SAMPLE and OPQRST methods. Important elements of the focused
history include:

Chief Complaint
Nature of illness/injury
Length of the illness/injury
Last Meal
Fever
Behavior changes
Vomiting/diarrhea
Urinary frequency

Medication/Allergies
Prescribed/OTC medications in the past week
Any known drug allergies
Medical History
Any hospital stays
Physician care
Chronic illness

Detailed Physical Exam

The physical exam in children should start from head to toe in older
children. But, the exam should proceed from toe to head in younger
children, normally < 2 yrs old. Depending on the child's condition the
following assessment may be appropriate:

Pupils: Check for round and reactivity to light

Capillary refill: Most accurate in children under 6 years old (<2
seconds is normal)
Hydration: Skin turgor >3 seconds to return, tears present, sunken
fontanelle indicates dehydration

Note: When assessing a child who is ill, it is important to note the

presence or absence of fever, nausea, vomiting, diarrhea, and urinary
frequency.

If time allows and the patient condition is potentially serious, monitoring

of the patient's vitals can provide valuable information. examples
include:

Blood oxygen saturation (SpO2)

BP assessment (>3 years old's unless medical command requests
it)
Body temperature
ECG (critical ill/injured)
Ongoing Assessment

The ongoing assessment should be considered appropriate for all

patients but, especially pediatrics and is performed throughout the
patient transport. The purpose is to monitor the patient for changes in:

Respiratory effort
Skin temp/color
Mental status
Vitals signs.

There are a number of pediatric resources and aids on the market that
break down most of the common medications and pediatric treatments.
The Broselow Tape is the most commonly used system used to calculate
drug and fluid dosages.
Patient condition including vitals should be assessed every 15 minutes in
a stable child and every 5 minutes if the patient is critically
ill/injured. EMS professionals must be capable of identifying any and all
immediate or potential life threats in a child. Obtaining a reliable history
and physical exam on a pediatric patient can be challenging at best, and
communication tactics are certainly important to their success. There are
several AHA certification programs for the proper treatment of pediatric
patients including PALS, PTLS, and many others. They will help to keep
you sharp and ready to face the various challenges of managing any
pediatric patient