Beyond the Basics: Pediatric Assessment and Management

Here's some simple, yet effective, tactics for pediatric assessment, along with a few pearls for success in procedural performance


LEARNING OBJECTIVES

• Discuss pediatric assessment tips
• Review pediatric respiratory emergencies
• Discuss pediatric vital signs

Click here to access a review test for your training purposes.

     EMS providers must be capable of identifying any and all immediate or potential life threats in a child. Obtaining a reliable history and physical exam on a pediatric patient can be challenging at best, and communication tactics are certainly important to their success. This article will address some simple, yet effective tactics for pediatric assessment, along with a few pearls for success in procedural performance.

ASSESSMENT PEARLS

A NEW EMS MNEMONIC FOR PEDIATRIC RESUSCITATION
     When you're conducting a primary and secondary assessment in a sick child, the following mnemonic provides a bit more detail than the traditional ABCs, highlights common pediatric-specific considerations and ensures steps are not missed in the examination:

Airway—Patency, positioning, breath sounds, obstruction

Breathing—Work of breathing, nasal flaring, grunting

Circulation—Heart rate, perfusion, pulses, skin temperature

Disability—Level of consciousness, response to environment

Remove all clothing and diapers

Fahrenheit—Determine body temperatures (hot, normal, cold)

Get—Vitals: temperature, pulse, respiratory rate, weight, BP

Head—Head-to-toe exam and history

Inspect—Inspect for evidence of trauma or signs of illness.

CHILDREN COMPENSATE BETTER THAN ADULTS
     It is often difficult to predict the severity of illness in a pediatric patient early in an injury or disease process, making it important for EMS providers to understand the compensatory mechanism variations between the adult and child.

     There are several distinctions between the adult and pediatric cardiovascular systems. First is that the adult heart increases stroke volume by increasing inotropy (strength of contraction) and chronotropy (rate of contraction) when the stroke volume decreases. In contrast, the pediatric heart can only increase chronotropy. The pediatric heart has a low compliance as it relates to volume and therefore cannot compensate by increasing stroke volume. Consequently, heart rate should be seen as a significant clinical marker when monitoring cardiac output in children. When the pediatric patient becomes bradycardic, it should be assumed that cardiac output has been drastically reduced.

     Children rely heavily on rate of respiration to compensate for respiratory difficulty. This is because they are unable to increase the depth of respiration due to the inability of the diaphragm to move farther downward against the compacted abdominal organs. Conversely, adults can increase rate and depth of respiration when they experience respiratory difficulty.

     Bearing these variations in mind, you should be able to more effectively predict when a sick child becomes a critical child. These variations should be considered in every child encountered in the field.

BREATHING IS EVERYTHING TO A CHILD… REMEMBER THE BASICS
     The common denominator for unexpected deaths in children is hypoxia. This encompasses a very diverse group of illnesses, including infectious diseases, choking, drowning, heart disease and pulmonary compromise. Unlike adults, children typically have a strong cardiovascular system and subsequently maintain cardiovascular function until they become extremely hypoxic. A child's metabolism is twice that of an adult's and thus requires much higher quantities of oxygen than the adult's. The body's source for oxygen comes from the pulmonary system, so it stands to reason that children with pulmonary problems will ultimately progress to cardiovascular compromise and eventually to death.

     When assessing a child with respiratory compromise, it is important to reduce, or at least not increase, the child's anxiety. Anxiety increases the workload of breathing, which may in turn exacerbate the pulmonary event. Simply keeping the child who does not present with immediate life-threats in the mother's, father's or primary caregiver's lap may be enough to reduce anxiety.

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