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 PREHOSPITAL CONSIDERATIONS

•           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
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 PREHOSPITAL CONSIDERATIONS

•           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
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

•           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
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 secretion.

                        MUSCULOSKELETAL      PREHOSPITAL CONSIDERATIONS

•           Newborns have two fontanels; the anterior Assessment of the anterior fontanel can indicate
closes between 10 and 16 mos and the posterior closes dehydration or increased intracranial pressure
between birth and 3 mos  Rib fractures are uncommon; provides minimal
•           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
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      PREHOSPITAL CONSIDERATIONS

•           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
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)

GROWTH & DEVELOPMENT CHARACTERISTICS

INFANTS (BIRTH TO 6 MONTHS)

                     CHARACTERISTICS                            APPROACH

•           Less than 2 months: Spend most of their               •           Relatively easy to assess; EMT or EMT-P can
time sleeping or eating approach without concern that presence may upset child

•           Between 2 and 6 months: more active;                  •           Doesn't matter if exam done in parent's arms or
constantly moving (extremities and head)              when not since there is no separation anxiety yet
fully alert
•           Exam can proceed "head-to-toe" or "toe-to-head"
•           No stranger or separation anxiety yet
•           Save things that may scare them for last (i.e.,
•           Strong or vigorous cry when healthy stethoscope)

•           Younger ones easily consoled with pacifier and

older ones are easily distracted by light or repetitive noise

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 •           Approach the toddler slowly and keep physical
and lasts until 3 years contact to a  minimum until he/she is familiar with you

•           Most toddlers resist logic, and they cannot be •           Stay low or at eye level with child; talk in a calm
reasoned with. and reassuring manner

•           Very mobile, opinionated and may be terrified of •           Allow toddler to remain with caregiver    
strangers
•           Use play or distraction to help with                      
•           Very curious and have no sense of danger assessment; introduce equipment slowly                and
encourage toddler to hold it
•           Older toddlers may remember earlier                    
experiences with doctors or nurses and                  be    Give him/her limited choices; helps provide toddler with a
fearful about being examined 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
ADOLESCENTS (12 TO 18 YEARS)
                     CHARACTERISTICS
•           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
PEDIATRIC PATIENT ASSESSMENT
•           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
                           APPROACH
•           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
     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

70 mm Hg plus twice
 
Systolic Blood Pressure the age in years
Age Heart Rate Respiratory Rate

(beats/min) (breaths/min)
Infant 100-160 30-60

Toddler 90-150 24-40

Preschooler 80-140 22-34

School-aged child 70-120 18-30

Adolescent 60-100 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 TECHNIQUES

•           Oxygen therapy - Administer oxygen for Various methods: nasal cannula with prongs cut
any child in respiratory distress or shock, or who is away, mask to face if tolerated, or some method of 
seriously ill/injured "blow-by" oxygen

            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
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.

            Flow rate 10 - 15 L/min Should be coordinated with child's breaths, if

present, to avoid coughing, vomiting, laryngospasm,
•           Position of comfort 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.)