The key to pediatric assessment in EMS is to identify and manage immediate life threats. It is often easy to determine whether a child is sick just by looking at him. Sick kids look sick. If a child is active, appropriate and alert, he is not sick. The opposite is true as well. If a child is inactive and non-interactive, assume he is sick until proven otherwise.
Forming a General Impression
The most widely accepted approach to forming a general impression in a child is using the Pediatric Assessment Triangle--an objective tool developed by the American Academy of Pediatrics that can be used to determine the severity of illness in a child. This tool is especially useful because the assessment criteria are determined during the general impression. This assessment can be performed from across the room, before contact with the patient is ever made. The triangle is composed of three sides: appearance, work of breathing and circulation.
- Appearance relates to the child's overall mental status, body position and muscle tone.
- Work of breathing relates to the visual effort or audible sounds associated with respiration.
- Circulation is assessed by determination of skin color.
Following implementation of the pediatric assessment triangle (PAT) to form a general impression, assess the child's level of consciousness, ABCs and vital signs.
It is important to realize that "normal vital signs" is a relative term. Children of various ages have different metabolic needs and therefore have different normal values. EMS providers should not rely on their memory to recognize normal versus abnormal vital signs. There are dozens of quick-reference charts or tools that can be used to aid in determining normal vital sign ranges. It is equally important to remember that there are few instances where a single vital sign or set of vital signs has any clinical significance. Vital signs are most beneficial and clinically relevant when they are used for trending changes in the patient's status over time.
The No. 1 cause of death in children is hypoxia. Lack of a patent airway or breathing adequacy is the most common reason for development of hypoxia. Studies suggest that in the majority of cases, children do not require prehospital intubation and tend to do well by bag-mask ventilation alone. It is for this reason that assessment of the pediatric airway is aimed at facilitating bag-mask ventilation. The MOANS mnemonic is used to identify a patient who may be difficult to ventilate with a bag-valve-mask device.
- Mask seal
- Age (greater than 55)
- No teeth
Successful bag-mask ventilation is dependent on just two factors: mask seal and a patent upper airway. A recessed chin, as seen in some congenital malformations, may make sealing the mask difficult. In the prehospital setting, when prolonged ventilation is necessary, a mask seal may become loose and ineffective due to muscle fatigue in the EMS practitioner's hands. Constantly monitor the mask seal to ensure there is no air leakage.
Obstruction is a consideration in pediatric patients. Obstruction of the upper airway may be caused by epiglottitis, angioedema or peritonsillar abcesses and can make the child's airway difficult to establish and manage.
Age is not a factor in pediatric airway management.
It is extremely difficult to create a mask seal in edentulous (toothless) patients due to the lack of a platform for the mask to rest upon to create an effective seal.
Stiff lungs require higher airway pressures to ventilate, and may result in difficulty in performing positive pressure ventilation. Bronchospastic conditions, such as asthma, are associated with higher airway resistance and may lead to more difficult ventilation states. Disease processes that create either compliance or higher airway resistance may create a situation in which increased ventilation pressures are necessary to generate adequate oxygen saturation.