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 9-1-1 and says her baby will not wake up. She is extremely anxious and emotionally distraught, and is unable to give the 9-1-1 operator any useful information. Upon arrival at the residence, the EMS crew notes a panicked mother holding a 6-month-old infant. She states 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 9-1-1.
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.
Begin your assessment from 10 feet away, carefully observing the following:
- 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.