Assessing the Pediatric Patient

Assessing the Pediatric Patient

Assessing the pediatric patient can be one of the most challenging and stressful tasks for prehospital providers. Pediatric education is very limited in most EMS curricula, and critical pediatric patients make up barely 1% of run volume in most EMS systems. Through the use of an observational assessment and application of age-appropriate assessment techniques, we can substantially decrease the difficulty in assessing our pediatric patients.


A mother calls 911 and says that her baby will not wake up. She is extremely anxious and emotionally distraught, and is unable to give the 911 operator any useful information. Upon arrival at the residence, the EMS crew notes a panicked mother holding a 6-month-old infant. She states that he was switched to a high-iron formula three days ago, and has had vomiting and diarrhea ever since. Today, he has been listless, with poor appetite. She put him down for a nap three hours ago and was unable to wake him up immediately prior to calling 911.

An observational exam of the child reveals:

  • Flaccid; does not react to being handed off to EMS providers 
  • Grimaces and withdraws briefly from pain stimulus 
  • Respirations are rapid and shallow, without audible airway noises or visible retractions 
  • Skin cool and dry, absent distal pulses and capillary refill of 4 seconds.

What information can we glean from this simple history and 10-second assessment without even taking vital signs? Quite a bit, actually. We know that the problem is cardiovascular rather than respiratory, most likely hypovolemic shock. The child’s mental status tells us that shock is already in the decompensated state and aggressive intervention and rapid transport are needed.

Differences in Anatomy and Physiology

Children are rate-dependent for respiratory and cardiovascular function. Unable to significantly increase cardiovascular stroke volume or respiratory tidal volume, they compensate by increasing heart and respiratory rate.

Due to underdeveloped thoracic musculature, infants and young children are unable to significantly increase respiratory tidal volume to meet oxygen demands. Use of neck and thoracic accessory muscles often results in muscle retraction without significant increase in tidal volume, contributing to respiratory fatigue.

Unable to significantly increase stroke volume, children respond to inadequate perfusion by increasing heart rate and dramatically increasing systemic vascular resistance. These compensatory mechanisms are often enough to maintain near-normal blood pressures while deeply in shock, but this compensation is brief. Decompensation can be precipitous and occur with little warning if the provider is gauging the degree of shock based upon blood pressure.

The airway of infants and young children is shaped differently from that of adults. The tongue is proportionately larger, the glottic opening is higher, and the trachea itself is hourglass-shaped, with the narrowest section immediately below the cricoid ring. Relatively little swelling or improper positioning can easily occlude the airway.

Children have impressive compensatory mechanisms, but those mechanisms have their price. Children have a higher basal metabolic rate than adults, and their oxygen and energy demands are correspondingly higher. Compensation for volume loss or respiratory compromise only increases these demands. Hypoxia and shock can occur quickly, and it is not uncommon for children to become hypoglycemic during or immediately after resuscitation.

Observational Assessment

Begin your assessment from 10 feet away, carefully observing the following:

Continue Reading
  • The child’s interaction with the environment. Does he react to your presence? Does he recognize parents or caregivers? Can he be calmed by a pacifier or favorite toy? If he is old enough to experience stranger or separation anxiety (older than 6 months), minimize your initial interaction.
  • Is breathing adequate, or are there audible airway noises, abnormal positioning such as tripod position, or retractions? Have the parent raise the child’s shirt and carefully observe respiratory mechanics.
  • What is the child’s perfusion status? Is capillary refill time less than 2 seconds, provided the room is warm? How many diapers has the child gone through today? Is the skin pale or cool? Have the mother blanch the top of the foot or hand and count the capillary refill time.

Primary Survey

Once you have gained a rough idea of the compromised systems and the child’s acuity level, begin a hands-on assessment. Your examination of the child in the scenario reveals:

  • HR 160 and thready, absent distal pulses
  • RR 40 and shallow, lungs clear bilaterally, no retractions
  • BP 70/40
  • Diaper contains a small amount of concentrated urine, and mother reports only one diaper change in past 12 hours.

In pediatric patients, the primary survey usually only confirms the impressions you obtained from your observational assessment. Vital signs are important, but limited at predicting the degree of instability of the child. In the scenario, the child’s blood pressure is normal for his age, but other assessment findings point to decompensated shock. Without rapid intervention, in five minutes this child’s BP may well be too low to obtain. 

Interpretation of vital signs should be age and developmentally appropriate. For infants, the minimum systolic blood pressure is 70. For children from 1-10 years of age, the minimum systolic blood pressure is 70 + 2x age in years. For children age 10 and older, the minimum systolic blood pressure is 90.

Secondary Survey

Technology is of limited benefit in field pediatric assessment. While cardiac rhythm monitoring, pulse oximetry and capnography are useful tools, the observational assessment and primary survey should yield enough clues to allow you to begin stabilizing treatment long before technological assessment is undertaken.

Management of tachycardia is rarely necessary for infants with a heart rate less than 220 or children with a heart rate less than 180. Bradycardia in infants and children is most often due to hypoxemia and should be treated first with oxygenation and ventilation. Blood glucose measurement should be obtained on all children with altered mental status.

Children with Special Healthcare Needs

Technology-dependent children present special problems for prehospital providers. These children may have significantly altered baseline mental status and vital signs. Their parents are usually more closely attuned to changes in their child’s status and should be viewed as the most authoritative resource on their child’s condition. Even subtle changes in status can herald potentially life-threatening complications, and the threshold for transport should be low. Whenever possible, transport these children directly to a specialty center or pediatric emergency department familiar with the child.


 Pediatric patients make up less than 10% of EMS run volume, and only 10% of those require emergent interventions. For the 1 in 100 patients who require more than BLS and a safe ride to the hospital, the most valuable clues to the child’s condition can be obtained from 10 feet away. Most children, even the sickest ones, can be effectively treated with BLS airway management and intraosseous infusion if emergent fluid replacement is necessary.

Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.

William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate’s degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and
urban settings. He lives in Tucson, AZ.


Many oppose officials nationwide who propose limiting Narcan treatment on patients who overdose multiple times to save city dollars, saying it's their job to save lives, not to play God.
After a forest fire broke out, students, residents and nursing home residents were evacuated and treated for light smoke inhalation before police started allowing people to return to their buildings.
Tony Spadaro immediately started performing CPR on his wife, Donna, when she went into cardiac arrest, contributing to her survival coupled with the quick response of the local EMS team, who administered an AED shock to restore her heartbeat.
A Good Samaritan, Jeremy English, flagged down a passing police officer asking him for Narcan after realizing the passengers in the parked car he stopped to help were overdosing on synthetic cannabinoids.

A family of four adults and five children died when a flash flood swept them away from the riverbank where they were relaxing.

A woman addicted to painkillers attempted to acquire a prescription for opioids but was arrested at the pharmacy when the pharmacist couldn't verify her prescription.

July 17—The early morning fire Monday that left 130 Charlotteans without a home—and seven people hospitalized—was intentionally set, the Charlotte Fire Department said.

Three of the people had serious injuries, according to Observer news partner WBTV.

Fire officials said 40 apartment units were affected by the fire at the Woodscape apartments on Farm Pond Lane. It took more than 50 firefighters an hour to put out the heavy flames, the department said.

The blaze caused more than $300,000 in damage, fire officials said.

Since there are inconsistencies in what details to report in drowning incidents, the AHA recommends medical professionals report when CPR was started, when it stopped and why, and ensuring quality resuscitation.
The sheriff believes officer safety is at risk and EMS response times are quick enough to treat overdose victims before police can.
To curb the increasing frequency of opioid overdoses, the State Department of Health calls for naloxone to be available both to first responders and the public.

Cardiac arrest is a leading cause of death in the U.S. but gets just a fraction of the government’s funding for medical research, according to a new study.

Researchers aren’t sure exactly why there’s such a disparity in funding from the National Institutes of Health, but say more is definitely needed considering about 450,000 Americans die each year from cardiac arrest. Most cardiac arrest victims don’t survive.

After CPR and multiple AED shocks failed to resuscitate a man who went into cardiac arrest, paramedics utilized the LUCAS 3 Chest Compression System, which delivers a rate of 102 compression per minute at a depth of 2.1 inches.

An electronic data-sharing system would flag patients who have requested opiate prescription refills three times or more in three months, a trend common among addicts called "doctor shopping."
Most of the overdoses are due to accidental exposure to substances belonging to their parents.
Roughly three out of four Americans believe that emergency care should be prioritized in having coverage in the new health care legislation that is currently being reviewed by the U.S. Senate.