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Case Study
You are dispatched to a rural clinic to transport a mother and her 2 year old child to a pediatric hospital. Upon arrival
you find the mother and child waiting in the reception room. The child appears to be sitting comfortably but you notice
that the child is staring blankly into space. You greet the mother and child and identify yourself. You notice that the child
is oblivious to your presence. The doctor on hand says that the child was reported to have been ill for the last week with
vomiting and diarrhea. The doctor has already established an IV line using a butterfly needle in the child's scalp. The
doctor says that he had great difficulty in finding a suitable vein. The doctor says that he administered 200ml of D5W
with no effect.
Your first impression is not a good one, you immediately begin your initial
assessment taking note that the child has an altered mental status. The
child's breathing is regular but the pulse is weak and rapid (you can barely
feel the child's radial and pedal pulses). The child otherwise appears to be
well perfused. You decide to transport immediately.
En route to hospital you put the child on supplemental oxygen. The child's
pulse oximetry is 95% and air entry to the lungs is equal and clear
bilaterally. The child's capillary refill is 3 seconds. You administer an
additional 200ml of fluid (based on the doctor's direction). You are not able
to obtain a blood pressure although the distal pulses are still present.
You assess the child's cardiac rhythm - a sinus tachycardia with a pulse rate
of 150. You gently pinch the back of the child's hand to test the turgor of the skin and it remains significantly tented for
at least a few seconds.
You reassess the child's mental status and the child seems to be a little more aware of it's surroundings. Using the CUPS
assessment you decide that the child is unstable due to the altered mental status and severe dehydration.
You ask you partner to radio the assessment information to the receiving hospital.
You ask the mother for the child's sample history and additional pertinent history. Nothing is out of the ordinary except
for the fact that the child has been vomiting and had diarrhea for the past week with very little fluid intake to replace
what was lost. It was only when the child stopped crying and began to look "dazed" that the mother decided to take the
child in for a check up.
Upon arrival at the hospital you hand the child over to the receiving staff along with your documented assessment
findings.
This case study highlights the fact that you are not always able to determine exactly what is wrong with a patient. You
must simply go through the numbers and intervene as necessary as you proceed through your assessment, and provide
rapid transport to the nearest most appropriate medical facility.
Introduction
Children are not simply small adults; the physiological, emotional and psychological differences as compared to adults
are profound. When faced with an injured or ill child, you may find yourself experiencing a great deal of fear,
uncertainty, lack of confidence and reserve. This is generally attributed to heightened emotions and lack of
preparedness and experience when dealing with pediatric patients.
Approach to Pediatrics
Gaining the trust of the child and parents is essential; failure to do so will make assessment of the child difficult if not
impossible and may even worsen the child's condition. It should be kept in mind that the child will most likely be
frightened by the following:
1. The illness or injury
2. The response of the childs family members to the child's illness or injury
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Remain calm
Stay at eye level with the child
Make yourself known to the child in friendly and simple terms.
Be cheerful and smile.
Be patient with the child
Be gentle when examining the child
6 months to 24
months
2 years to 3
years
3 years to 5
years
5 years to 12
years
12 years to 18
years
Scene Size Up
Scene size-up remains the same as for adults with a few exceptions. If you know that the incident involves pediatrics,
you should mentally prepare yourself for the challenge ahead.
As you approach the patient, you should try to get an overall assessment of the patient. Some questions that you
should ask yourself are:
1.
2.
3.
4.
5.
Based on the outcome of the above assessment, you should decide whether IMMEDIATE interventions are required, or if
you should take a more relaxed approach to gain the child's trust. It must be pointed at that the initial assessment
must be stopped as soon as a critical condition has been identified and the appropriate interventions should be made.
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assessment you use the AVPU scale to further assess the mental status of the child. The AVPU scale fortunately works
as well for pediatrics as it does for adults with the only exception that the severity of the child's condition between the
different levels is far greater than with adults. Anything other than "Alert" should be considered a grave sign in a
pediatric patient.
A
V
P
U
The
The
The
The
child
child
child
child
is alert, opening its eyes looking around, crying, moving its limbs spontaneously.
responds only to Voice.
responds only to painful stimulus.
is unresponsive.
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An evaluation of the efficiency of the child's respirations i.e. rate, rhythm, depth and effort
Auscultation of breath sounds
Assessment of skin color e.g. pink, pale or cyanosed
Use of pulse oximetry
Evaluation for any trauma to the chest
The steps to follow to adequately assess breathing are:
1. Assess the adequacy of the child's respiratory rate.
To do this count the number of time the chest or abdomen rises and falls during a 30-second period and
multiply that figure by two to get the rate/minute e.g. a count of 35 respirations in 30-seconds would work
out to 70 respirations per minute (35 x 2 = 70).
Normal values for a child's respiration rates are:
Neonates
(up to 7lbs)
Respiration
Rate
1 month to 1
6 to 10
2 to 6 years
year
years
(from 22 to
(from 7 to
(from 44 to
44lbs)
22lbs)
75lbs)
30-70
20-40
20-30
20-25
10 to 18
years
(from 75 to
110lbs)
15-20
If the child's respirations are outside of the above ranges it means that the child is not receiving sufficient
oxygen or discharging sufficient carbon dioxide.
2. Assess the depth of the child's respirations
This is an indication of the volume of air being moved during respiration. Even if a child's respiration rate is
normal, a respiratory depth that is very shallow is considered to be inadequate respiratory effort that will
require intervention.
3. Assess the child for signs of increased respiratory effort
Signs of increased respiratory effort include:
Retractions on inhalation - where the skin appears to pull in into the sternal notch, above the
clavicles, between the ribs (intracostal retractions) or below the ribs (subcostal retractions)
Nasal flaring - a widening of the nostrils in infants and toddlers to allow more air to enter the airway
Bobbing head - the head lifts and tilts back on inhalation and falls forward on exhalation.
4. Assess the child's breath sounds
First listen for sounds that are audible without the use of a stethoscope. Such sounds are a sign of
increased respiratory effort.
Place a stethoscope on each of the mid-axillary lines (beneath the armpits) and compare the sounds
between the left and right lungs (the sounds should be the same). The stethoscope should not be placed at
the nipples as the small size of the child's chest may cause sounds to be transmitted from one side of the
chest to the other.
Listen for abnormal breath sounds. Abnormal breath sounds include:
Grunting - a whining or "uh" sound on expiration.
Wheezing - either a high- or low-pitched sound heard on expiration. Expiratory wheezing is usually
a sign of bronchoconstriction
Stridor - also a high- or low-pitched sound that is heard on inspiration. Stridor is usually a sign of an
obstructed airway.
Rhonchi - a sound heard when the airways are blocked by thick fluid or muscle spasm. Rhonchi is
rumbling sound that is clearer on expiration and coughing.
Crackles/Rales - this is a fine, bubbling or crackling sound is most often heard on expiration but
may also occur on inspiration. Crackles is a sound of fluid build up in the alveoli.
Gurgling - this is a coarse bubbling sound that is heard on both inspiration and expiration. Gurgling
is a sign of liquids in the airway. Suctioning is required.
Identifying one or more of the above sounds (if they are present at all) will give you a much clearer
picture of the child's condition. The most dangerous of all the sounds is actually no sound at all. You should
at least hear normal breath sounds.
SpO2
Condition of child
From 95 to 100%
Normal
Severe hypoxia
The pulse oximeter reading changes frequently and is to be used as adjunct only. A pulse oximeter can
never be used to determine if oxygen should be withheld - TREAT YOUR PATIENT, not your equipment.
Breathing Assessment Interventions
If there is any indication of respiratory compromise the following steps should be followed:
Administer high-flow oxygen at high concentrations for any sign of respiratory compromise such as:
Variations in rate, depth or effort of breathing
Abnormal breath sounds
Cyanosis
For infants in respiratory distress deliver as close to 100% oxygen as possible.
Assist ventilations with a bag-valve-mask and supplemental high-concentration oxygen in all cases where there is
inadequate ventilation or respiratory failure/arrest.
If present, treat bronchoconstriction with supplemental oxygen and the appropriate medications.
Seal any sucking chest wounds with a one-way valve type dressing (to allow air to escape the chest but not to
enter it).
If the child shows the signs of tension pneumothorax (distended neck veins, tracheal deviation, anxiety, cyanosis,
decreased lung compliance etc) the pressure inside the chest must be released by means of a needle
thoracocentesis.
Cardiac arrest in children is generally secondary to respiratory failure and should always be closely monitored. A child's
breathing should not only be assessed by respiration rates alone, but the child's entire clinical picture should be taken
into account. Such clinical signs that should be considered are (in no particular order of priority):
1.
2.
3.
4.
5.
6.
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Level of consciousness
The child's agitation levels
Cyanosis
Cardiac status (BP, rate, rhythm and strength of pulse etc.)
Mechanism of injury
Chest auscultation (air entry should be equal bilaterally and clear)
120-150
115-130
80-115
85-100
70-80
Concerns should be raised if the pulse rates are outside of the above values.
If the child is being uncooperative and taking a pulse proves difficult, try and take the pulse rate by
listening to the heart with a stethoscope. The best site for listening to the heart is between the child's
nipple and breastbone on the left side which is directly over the apex of the heart.
The formula for estimating the pediatric upper limit heart rate is: Rate = 150 - (5 x age in years) e.g. a
child of 6-years of age will have an estimated upper heart rate of 150-(5 x 6) = 150-30 = 120 beats per
minute.
5. Check the skin color:
Color
Condition of Child
Pink
Normal
Pale
Bluish
Abnormal / Hypoxia
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Blood pressure should only be measured after the respiration and pulse rates have been measured.
Children are often agitated by the process of having their blood pressure taken which will artificially
elevate the respiration and pulse rates. Select an appropriately sized blood pressure cuff (one that is 2/3
the size of the upper arm or thigh, the upper arm being preferable).
The table below shows the average blood pressures for the various age groups.
Blood Pressures for the Various Age Groups
1 month to
6 to 10
10 to 18
2 to 6 years
Neonates
1 year
years
years
(from 22 to
(up to 7lbs)
(from 7 to
(from 44 to (from 75 to
44lbs)
22lbs)
75lbs)
110lbs)
Average Blood
Pressure
74/40
85/60
90/60
95/62
105/65
To estimate the lower limit of a child's systolic blood pressure use the following formula: BP = (2 x age in
years) + 70 e.g. a child that is 10-years old will have an estimated lower limit systolic blood pressure of (2
x 10) + 70 = 20 + 70 = 90 systolic.
9. Assessing the child's cardiac rhythm. A child or infant that has any of the following should have continuous cardiac
monitoring:
Decreased level of consciousness
Abnormal airway assessment
Abnormal breathing assessment
Bradycardia
Tachycardia
Any sign of decreased perfusion
The cardiac monitor should only be placed on the child once the initial assessment and required
interventions have been performed. If any changes are noted in the child's cardiac rhythm, the changes
should be correlated with any other changes in the child's condition. Dysrhythmias in children should only
be treated if they compromise the child's breathing or circulation, or if the dysrhythmia is likely to degrade
into a lethal rhythm e.g. ventricular tachycardia.
If a child's pulse is absent, rapidly determine the rhythm to see if either pulseless ventricular tachycardia
or ventricular fibrillation is present, if so the child must be immediately defibrillated.
Circulation Assessment Interventions
If the child has a pulse of less than 60 beats per minute AND is receiving assisted ventilations - begin cardiac
compressions. Do not begin cardiac compressions based on the absence of pulse alone as it is difficult to locate a child
or infant pulse (even at the best of times). A child requiring cardiac compressions will show clear signs of inadequate
perfusion, will be unresponsive and will be unable to breathe adequately. Compressions should be performed at the
following rates:
For children under 8-years of age - one ventilation after every five compressions (pause during the ventilation)
until the child is intubated. Once intubated the pause is no longer required.
For children over 8-years of age - two ventilations for every fifteen compressions (pause during the ventilations)
until the child is intubated. Once the child is intubated switch to a ratio of one ventilation for every five
compressions with no pause for ventilation.
Children have excellent compensatory mechanisms and can maintain a normal blood pressure during the initial stages
of shock. Once the compensatory mechanisms begin to falter, they do so quickly and the child's condition can rapidly
deteriorate. Signs of shock must be treated aggressively as they occur and the underlying cause of shock should be
treated if possible. Treatment for shock includes:
Administration of high-concentration oxygen (this should be done during the airway/breathing assessment)
Control any massive external bleeding. Children have far less blood than adults and even the smallest amounts
of blood loss can have serious consequences.
Unless contraindicated by possible injury, elevate the child's legs to above the level of the heart.
Obtain IV access and administer a bolus of either saline or Ringer's lactate at 20mL/kg IV push. Repeat the fluid
bolus up to three times if shock persists. DO NOT unnecessarily delay transport to set up an IV.
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Prevent body loss of body heat by wrapping the child in a space blanket. Small children are more susceptible to
loss of body heat than adults.
Interventions for Dysrhythmias
Bradydysrhythmias
The most common cause of bradycardia in children is hypoxia. First reassess the child's airway and
breathing to ensure that oxygenation and ventilations are adequate. If they are adequate and the child
appears to be well perfused, no further action is needed. If the child shows signs of poor perfusion, the
dysrhythmia should be treated as per local protocol e.g. administration of pharmacologic agents and the
use of cardiac pacing.
Tachydysrhythmias
First it must be determined if the dysrhythmia is a wide or a narrow complex.
Wide complex tachydysrhythmia
If the patient shows signs of cardio-respiratory insufficiency, cardioversion or pharmocologic
treatment may be required.
Narrow complex tachydysrhythmia
Determine if the rhythm is a sinus tachycardia which will most likely be cause by easily
correctable mild hypoxia or hypovolemia. If the dysrhythmia is NOT a sinus tachycardia the
child's perfusion should be carefully reevaluated. If there are signs of cardio-respiratory
insufficiency then either immediate cardioversion or cardioversion with pharmacologic agents
should be performed.
CUPS Assessment
After the initial assessment is complete, do a CUPS assessment:
C - Critical
U - Unstable
Breathing is absent or
child is having great
difficulty in breathing.
Airway, breathing or
circulation are
compromised.
Increased difficulty in
breathing.
Bradypnea or
Tachypnea.
tachypnea with
intermittent periods of
apnea.
P - Potentially
Unstable
S - Stable
Normal respirations.
Child is cyanosed or
pale.
Child is pink.
The CUPS assessment will help you determine whether to do further assessment on scene or initiate urgent transport to
the nearest medical facility.
If the child is critical or unstable, perform only critical interventions (ABC's) on scene and transport the patient
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immediately.
If the child is potentially unstable do the initial assessment and transport without delay. "Potentially unstable" includes a
wide variety of conditions that are based upon the child being anything other than "Normal" even though the child does
not appear to be in distress. A dangerous mechanism of injury can class a child as potentially unstable even if the child
appears perfectly fine.
If the child is stable, a complete focused exam and history can be completed before transport. As you progress with
your treatment, it may be necessary to reassess your initial CUPS finding and react accordingly.
Reassessment
As mentioned earlier, a child's condition can deteriorate rapidly. Assessment should be ongoing until arrival at an
appropriate medical facility and hand over to the emergency room staff. Continuously monitor all elements of the initial
assessment as well the vital signs and CUPS assessment.
Vital Signs
Vital signs are age specific, although it is extremely difficult if not impossible to accurately remember the vitals signs for
the different age groups, it must be kept in mind that a 10 year old with the vital signs of a 10 month old would be in a
serious condition. You should keep a copy of pediatric vital signs in your equipment bag. The table below summarizes
the various vital signs for the different pediatric ages groups:
Breathing, Pulse and BP
Age
Weight (Lbs)
Average BP
Pulse
Respirations
74/40
120-150
30-70
85/60
115-130
20-40
90/60
80-115
20-30
95/62
85-100
20-25
105/65
70-80
15-20
up to 7
Neonates
from 7 to 22
1 month to 1 year
from 26 to 44
2 to 6 years
from 44 to 75
6 to 10 years
from 75 to 110
10 to 18 years
The above are merely a guideline. Always be sure to get the big picture and assess the condition of a child as a whole.
It is also important to take the childs size into account, some 4 year olds are the size of 8 year olds.
Pediatric Glasgow Coma Score
The Pediatric Glasgow Coma Score is a modified version of the Adult Glasgow Coma Score and takes into account the
limited vocabulary and communication skills of pediatric patients. A copy of the Pediatric Glasgow Coma Score should
be kept in the rescuers equipment bag as remembering it while under stress will be unlikely.
Children over the age of 5 years can generally be assessed using the adult Glasgow Coma Score.
Eyes
Verbal
Motor
4 Localization of pain
Abnormal Flexion
(decorticate rigidity)
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No Verbal response
1 No motor response
Abnormal Extension
(decerebrate rigidity)
It should be noted than when recording a GCS it is not helpful to simply write down 12/15 or 4/15, the individual items
should be noted as well e.g. Eyes - 3, Verbal - 2 and Motor - 5. The reason for this is that although one aspect of the
child's GCS may improve, another may decline e.g. an initial assessment of the child's GCS reveals Eyes - 3, Verbal 4
and Motor 4 (totaling 11/15), a few minutes later the child's GCS is Eyes -2, Verbal -3 , Motor - 6 (totaling 11/15).
Although both GCS's are 11/15 the clinical significance of each is vastly different.
Focused Assessment
With seriously sick or injured pediatric patients initial interventions and early transport are a priority. Additional
background information and history should not delay transport but should rather be taken en route to hospital if
accompanied by the parents of the child.
If there are sufficient personnel on scene, one team member can obtain a focused history while the other team
members do the initial assessment and perform the necessary interventions.
If the child's condition is urgent, the history taking must not delay the child's transport to hospital.
If the child is non-urgent a more detailed history of the child's condition can be collected. Typically the history is
obtained from the parents but should the child be old enough they should be given the opportunity to answer questions
for themselves.
SAMPLE History
S
ALLERGIES
This information can be obtained from medic alert bracelets or family members. Special
note must be taken of any allergies to any medications.
MEDICATIONS
Medicine (prescription or otherwise) that the child has taken that day, or takes regularly.
Again, this information would have to be obtained from a family member, alternatively
the information can be obtained from medicine bottles (do not waste time trying to
determine what the child took).
LAST MEAL
At what time did the child last eat, what did the child eat (is it something the child
normally eats), was it a regularly scheduled meal, has the child being eating normally?
EVENTS
What caused the paramedics to be summoned to this patient? If the child is an asthmatic
and has regular attacks, what is different this time that the paramedics were called?
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Once the SAMPLE history has been completed, you should determine if any of the additional findings will alter the CUPS
assessment and act accordingly.
Additional history
You should also inquire into and take note of any injury or illness specific to:
1. Mental status
Have there been any changes in the child's behavior or level of consciousness?
Has the child been them self lately?
Has the child suffered any illness or injury that caused them to lose consciousness or be "dazed".
2. Airway
Has the child suffered from an asthma attack or upper airway infections?
Has the child ever had a tracheotomy?
3. Breathing
Have there been any changes in the child's breathing patterns?
Has the child ever stopped breathing?
4. Circulation
If there is any external bleeding and you yourself were not able to see the amount of blood lost,
ask the parents to estimate the amount of blood lost in layman's terms.
Inquire as to whether the child has been vomiting or has had diarrhea, and for how long.
Also make inquiries into what the child's fluid intake has been like for the past few days.
If possible try and determine how often the child has urinated.
5. Trauma
Determine if the child has suffered any major trauma in the recent past e.g. unrestrained motor
vehicle collision, fall from significant height, pedestrian vehicle accident, fall from bicycle (helmet?)
6. Neurological history and developmental history
Has the child suffered from any seizures?
If so try and determine when, for how long, the frequency and the child's behavior before and after
the seizures.
Did the child have a fever prior to the seizure?
7. Fever
Try to determine if the child's temperature has been taken recently, what that temperature was and
how the temperature was taken i.e. oral, rectal or tympanic.
Did the child have any neurological changes during the fever.
Find out what anti-pyretic medications were given to reduce the fever.
Has the child suffered any serious infections?
Has the child's doctor recommended any special care during a fever?
8. Poisonings
If a child is known or suspected to have ingested or otherwise been exposed to a poison try an
determine how the poisoning occurred, what the poison was, how much may have been ingested
and whether any "home remedies" were given to the child for the poisoning.
Ask if the child has had any seizures, cramps, nausea, vomiting or changes in behavior
Discretely try and determine whether this was a suicide attempt
9. Burns
Determine the source of the burn e.g. fire, steam, electricity, chemicals
Determine the location and extent of the burns on the child's body
Carefully assess the child's mouth and nose for signs of inhalation burns.
Ask if there has been any change in the child's mental status.
10. Near-drowning
Find out how long the child was immersed.
Was there any chance of spinal injury?
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DCAP-BTLS
Examine what is most painful LAST and what concerns the parents most FIRST.
Deformities
Continually reassure the child during the exam and gain the child's trust. Encourage
the parents to assist with the physical examination.
Contusions (bruising)
Head
Gently palpate the head and feel for any skull irregularities or soft, spongy areas.
Feel for crepitus (bone crunching sound). If any of the aforementioned are present
the child should be considered critical.
Abrasions
Punctures/Penetrations
Burns
Tenderness
Lacerations
In infants the "soft spot" should be carefully examined. A bulging soft spot with a
Swelling
history of trauma can indicate increased intracranial pressure. A bulging soft spot
with a history of fever can indicate meningitis. A sunken soft spot is an indication of dehydration.
Eyes
Assess the pupils, they should be PEARRL (Pupils equal and round and reactive to light). Both
pupils should be equal and they should constrict when a penlight is shined into them and
dilate when the light is removed. Unequal pupil reaction with a history of trauma is a sign of
potential brain damage. Look for ecchymoses (bruising) beneath the eyes which is a sign of
base of skull fracture.
If there is an injury to either of the eyes, BOTH eyes should be dressed. This helps reduce
the movement of the eyes.
Nose
Check the nose for deformity or if there is any clear, straw-colored fluid (CSF - cerebro-spinal
fluid)or blood draining from the nose. If you suspect CSF is leaking the child should be
considered to be critical.
Mouth
Although the mouth should be checked under airway and breathing, reassess for any soft
tissue damage or damaged teeth. Do not stick anything into the child's mouth.
Assess the mouth for dryness which may be a sign of dehydration or hypovolemic shock.
Ears
Examine the ears for any leaking blood or CSF. Ecchymoses behind the ears is a sign of base
of skull fracture.
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Neck
The child's trachea should be midline. If the trachea is deviated to either side (a sign of potential tension
pneuomthorax caused either by trauma or severe asthma) the child should be immediately reassessed for
respiratory difficulty.
Although difficult to detect in smaller children, distended neck veins may present in the case of fluid accumulation
in the pericardial sac.
If no trauma has been sustained the neck should be gently assessed for any stiffness (meningitis). This
accompanied with a history of fever may put the child at risk for altered mental status, respiratory distress and
shock.
If trauma is suspected, have cervical spine support maintained while gently feeling the back of the neck for any
tenderness, deformity or crepitus - all of which may indicated spinal injury. If a cervical spine injury is suspected
particular attention must be paid the child's respiratory status and motor reflexes.
Chest
Check both sides of the chest for DCAP-BTLS.
Check for crepitus or abnormal movement of the ribs.
Assess for signs of respiratory distress if any of the above are present.
Auscultate the heart for any irregular or extra sounds e.g. murmurs, skipped beats, clicks etc
Auscultate the chest for breathing sounds over all the appropriate points. Take note of any wheezing, Rhonchi or
crackles. Make sure that the breathing sounds are equal bilaterally. If the sounds are unequal pneumonia,
pneumothorax or tension pneumothorax may be present.
Abdomen
Check the abdomen for DCAP-BTLS.
Use care when palpating the abdomen for tenderness.
Take note of any guarding (the child stiffens the abdominal muscles).
Reassess the child's circulatory status if guarding and/or tenderness is present.
Reassess the child's breathing status if the child has been crying incessantly and the abdomen is distended.
Children may swallow a lot of air when crying which results in the abdomen being distended. An abdomen
swollen from swallowed air is indicated by an enlarged left upper quadrant where the stomach is situated. The
enlarged stomach put pressure on the diaphragm making it more difficult for the child to breath.
Pelvis
Check the hip bones for DCAP-BTLS
Check the pelvis for stability taking note of any abnormal looseness or crepitus.
If the pelvis is unstable, reassess the child for signs of shock.
The mechanism of injury required to fracture a pelvis requires significant force and a high index of suspicion for
additional injuries should be maintained.
Genitals
If the child has any complaints in the genital area, assess for DCAP-BTLS.
Extremities
Check radial pulses, capillary refill and warmth in all extremities. Absence of pulses and abnormally cool
extremities indicate poor perfusion to that area especially if one limb is noticeably different to the other. In this
case the limb may be threatened and the child's condition is urgent and must be rapidly transported to hospital.
Check motor function and nervous reflex in all extremities.
Check the extremities for DCAP-BTLS
Compare the extremities being examined to one another, take note of any difference or deformities. If there is
any deformity, tenderness or ecchymoses the limb should be immobilized.
If the movement in the limbs is unequal, immobilize the limb and the spine. Unequal movement can occur as a
result from the pain of trauma or muscle, nerve or brain damage.
A child's bone is most likely to break at the point of the growth plates (near the joints). A fracture is almost
always has accompanying ecchymoses.
Back
Check the back for DCAP-BTLS.
If there is any tenderness, ecchymoses or crepitus present the child should be immobilized.
If a spinal injury is already suspected, the child's back should be checked when the child is being log rolled onto
the spine board.
Skin
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First impression
Findings during the initial assessment and the interventions performed
Findings from the focused history (if taken)
Vital signs including the times they were taken
Finding during the physical examination
All treatments and the patient's response to those treatments
All findings from reassessments, as well as reasons for any reassessments e.g. you noticed the skin color change
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