Beyond the Basics: Pediatric Assessment

More than 20,000 pediatric deaths occur each year in the United States.

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More than 20,000 pediatric deaths occur each year in the United States. This disturbing number validates how important it is that EMS providers are educated to effectively assess and manage the critical pediatric patient. Providing the best care possible can only be achieved by obtaining an appropriate history, coupled with an accurate physical exam. EMS providers must be capable of identifying any and all immediate or potential life threats in a child.

Airway Anatomy & Physiology
It is important to identify differences between adult and pediatric anatomy and physiology. The anatomical and physiologic variations between adults and children can cause confusion if the EMS provider does not fully understand these differences.

One of the most obvious anatomical differences between an adult and child is the tongue. The pediatric tongue is larger than the adult in relation to the amount of free space in the oropharynx. The large tongue creates a significant probability for airway occlusion and leaves little room for airway swelling. The size of the tongue is thought to be one explanation for why children are obligate nose-breathers: breathing through the nose is easier because it provides a direct path for airflow without concern for any obstruction that the tongue may cause.

The pediatric trachea is much more pliable and smaller in diameter than the adult and has immature tracheal rings. The increased pliability of the trachea can be troublesome in the pediatric patient because hyperextension or hyperflexion of the neck may lead to complete or partial occlusion of the airway. The small diameter of the trachea allows for only a minimal amount of swelling before significant compromise of airflow occurs.

The pediatric epiglottis tends to be large and is more u-shaped or oblong, making it more difficult to control when attempting intubation. There are a variety of practices related to pediatric intubation, including the preferential use of a straight (Miller) blade versus a curved (McIntosh) blade. The reason for this preference is attributed to the unique shape of the epiglottis: The curved blade fits into the vallecula and indirectly lifts the epiglottis from the glottic opening, whereas the straight blade is inserted under the epiglottis and directly elevates it for visualization of the vocal cords. This allows for better control of the epiglottis. The long epiglottis can easily flop down around the curved blade and cause visual obstruction of the glottis and vocal cords.

The position of the adult larynx is at about the level of the fourth or fifth cervical vertebrae; the pediatric larynx is at about the level of the first or second cervical vertebrae. If the pediatric larynx were lower, children would aspirate food into the trachea as they swallow. This is an important anatomical airway consideration, since the higher larynx is more anterior.

The mainstem bronchi in young children have less angle than in adults. As a result, aspiration can occur in either the left or right mainstem bronchi. As children grow, an increase in chest diameter causes the angle of the left bronchus to increase as well.

Red Flags in Pediatric Assessment
There are several clinical signs that must be considered when assessing a sick child. If any of the following signs are present, aggressive intervention should be employed as quickly as possible to prevent the child from going into cardiopulmonary arrest.

  • Respiratory rate greater than 60
  • Significant hemorrhage
  • Respiratory distress or failure
  • Significant trauma
  • Nasal flaring
  • Alterations in mentation
  • Uncorrected noisy respiration
  • Seizures
  • Cyanosis
  • Fever or history of fever with a global rash
  • Mottling
  • Heart rate greater than 180 bpm
  • Pallor
  • Heart rate less than 60

Cardiovascular Anatomy and Physiology
Although the pediatric and adult heart share identical anatomy, several important distinctions need to be made between the adult and pediatric cardiovascular systems.

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