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 911 and says that her baby will not wake up. She is extremely anxious and emotionally distraught, and is unable to give the 911 operator any useful information. Upon arrival at the residence, the EMS crew notes a panicked mother holding a 6-month-old infant. She states that 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 911.
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.
Once you have gained a rough idea of the compromised systems and the child’s acuity level, begin a hands-on assessment. Your examination of the child in the scenario reveals:
HR 160 and thready, absent distal pulses
RR 40 and shallow, lungs clear bilaterally, no retractions
Diaper contains a small amount of concentrated urine, and mother reports only one diaper change in past 12 hours.
In pediatric patients, the primary survey usually only confirms the impressions you obtained from your observational assessment. Vital signs are important, but limited at predicting the degree of instability of the child. In the scenario, the child’s blood pressure is normal for his age, but other assessment findings point to decompensated shock. Without rapid intervention, in five minutes this child’s BP may well be too low to obtain.
Interpretation of vital signs should be age and developmentally appropriate. For infants, the minimum systolic blood pressure is 70. For children from 1-10 years of age, the minimum systolic blood pressure is 70 + 2x age in years. For children age 10 and older, the minimum systolic blood pressure is 90.
Technology is of limited benefit in field pediatric assessment. While cardiac rhythm monitoring, pulse oximetry and capnography are useful tools, the observational assessment and primary survey should yield enough clues to allow you to begin stabilizing treatment long before technological assessment is undertaken.
Management of tachycardia is rarely necessary for infants with a heart rate less than 220 or children with a heart rate less than 180. Bradycardia in infants and children is most often due to hypoxemia and should be treated first with oxygenation and ventilation. Blood glucose measurement should be obtained on all children with altered mental status.
Children with Special Healthcare Needs
Technology-dependent children present special problems for prehospital providers. These children may have significantly altered baseline mental status and vital signs. Their parents are usually more closely attuned to changes in their child’s status and should be viewed as the most authoritative resource on their child’s condition. Even subtle changes in status can herald potentially life-threatening complications, and the threshold for transport should be low. Whenever possible, transport these children directly to a specialty center or pediatric emergency department familiar with the child.
Pediatric patients make up less than 10% of EMS run volume, and only 10% of those require emergent interventions. For the 1 in 100 patients who require more than BLS and a safe ride to the hospital, the most valuable clues to the child’s condition can be obtained from 10 feet away. Most children, even the sickest ones, can be effectively treated with BLS airway management and intraosseous infusion if emergent fluid replacement is necessary.
Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.
William E. (Gene) Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate’s degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings. He lives in Tucson, AZ.