Once pulmonary compromise is identified, determine a plan of emergency care. If the airway is intact, and there is no obstruction, the child may simply need coaching to take a deep breath to improve ventilatory status. Although there are numerous methods for eliciting deep breaths in children, these methods seem to work fairly well.
- Most children are familiar with the fairy tale about the three little pigs and the big, bad wolf. Use that story and have the child "huff and puff" like the wolf. This is an easy way to coach them to take a breath and is also helpful when trying to auscultate lung sounds.
- Another technique is to have them "blow out" a penlight. When deeper inspirations are needed, ask the child to "blow harder."
- Assuming the child is old enough to not be at risk for swallowing a balloon, ask him to blow up a balloon while you auscultate his lungs. This works well, and the child will have the balloon to play with during his stay in the emergency department.
A simple and quick pulse oximeter reading immediately yields information regarding oxygenation status, but also provides an indication of peripheral perfusion. A normal pulse oximeter reading is another clinical indicator in confirming an adequate peripheral perfusion status. If the pulse oximeter reading is abnormal with the probe attached to a peripheral site, consider moving the probe to a more central location like the earlobe or bridge of the nose. A poor peripheral SpO2 reading with a good central oximetry reading is most likely a result of poor perfusion rather than respiratory insufficiency. The exception to this rule is the child with breathing abnormalities.
Capillary refill time is typically quite accurate in children and considered to be reliable in most cases. Healthy children do not have the vascular disease adults may; therefore, capillary blood flow is very responsive and typically refills normally within 2 to 3 seconds. Just as in the adult patient, environmental factors like cold ambient temperatures can prolong capillary refill times. For this reason, capillary refill time should be assessed closer to the core in areas like the kneecap or forearm. If a cold environmental temperature is a concern during assessment, find a warm area on the body to assess for capillary refill.
SYNCOPE VERSUS SEIZURES
Lay people and EMS providers alike may have difficulty differentiating a syncopal episode from a seizure in the pediatric population. When responding to the scene of an unresponsive child, given the high stress associated with pediatric medical emergencies, obtaining a good history of events can be difficult.
Incontinence is an uncommon finding in a syncopal episode, but is common in seizure activity. It is important to note, however, that this finding is not reliable in a diaper-dependent child, since it is difficult to determine the time the diaper was soiled in relation to the physiologic event. Syncope does not present with any history of tonic-clonic activity and typically occurs with generalized symptomatology. In contrast, a seizure patient often has a recent history of generalized tonic-clonic activity or localized focal motor activity.
In addition to physical assessment findings, determining the duration of loss of consciousness may help to determine if the etiology is related to syncope or seizures. In a syncopal event, there is generally a relatively short duration (less than five minutes) of unconsciousness, in contrast to a relatively longer duration (greater than five minutes) in a seizure.
Next time you need to calm a toddler for an examination, try running through a practice exam on a stuffed animal the child is holding or on an older sibling or parent. During the exam, search for characters the child can relate to (such as Disney characters). Children get involved in the game and their stress reduces.
It can be difficult to gain the cooperation of toddlers undergoing an examination. It may be helpful to ask children if they are ticklish as you gently tickle their ribs, axilla or neck. Explain that the examination may tickle the same way, so they expect to feel something. Talk to the child throughout your exam, and tell them it is okay to giggle but not to wiggle. This may sound cheesy, but it actually works.