Beyond the Basics: Pediatric Assessment and Management
• Discuss pediatric assessment tips
• Review pediatric respiratory emergencies
• Discuss pediatric vital signs
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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.
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.
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.
A NEW PARADIGM IN PREHOSPITAL PEDIATRIC VENTILATORY MANAGEMENT
It is often believed that ventilating a child can be well accomplished in the field using a pediatric bag-valve-mask device. While it is true that a pediatric BVM can be used to ventilate a sick child, it is not the optimal device.
In a study published in the journal Respiratory Care, experienced respiratory therapists were asked to ventilate a pediatric test lung to determine their ability to identify changes in ventilatory compliance. While these experienced practitioners recognized a change in compliance 65% of the time, they could not effectively identify the overall tidal volume delivered to the child. The recommendation from this study was that a standard BVM is not the optimal tool for managing a pediatric airway.
The optimal ventilation device is an anesthesia bag with a manometer attached to measure peak inspiratory pressures (PIP). Using this device will allow you to actually monitor real pressures delivered to the child's airway to ensure that the tidal volume delivered is on target with the child's physiologic demands. There is a significant body of evidence suggesting that overinflation of the lungs has untoward effects on a child's morbidity and mortality rates.
We are not advocating that all EMS systems transition pediatric ventilatory management to anesthesia bags, but rather want to highlight the potential for poor ventilation in the pediatric population. If a seasoned respiratory therapist (who ventilates children on a more regular basis) has difficulty in determining ventilatory compliance, all EMS providers should take pause when ventilating children with a BVM. Be sure you are cognizant of the risks associated with bag-valve ventilation.
YOU CANNOT REMEMBER NORMAL WEIGHTS, RESPIRATORY RATES, BLOOD PRESSURES, HEART RATES, AND CALCULATE DRUG DOSES IN YOUR HEAD SO DON'T TRY….
There are several factors that can impact the potential for clinical errors in managing a sick child, including unique drug doses (compared to traditional adult doses), choice of equipment size, and fluid and ventilatory volumes necessary to a successful resuscitation effort. Combine these factors with the high stress environment and impaired cognitive ability in such a scenario and the risk for error is high. It is therefore recommended that a length-based tape or the like be used to ensure that the human error factor is eliminated, or at least substantially mitigated.
A study led by Amit Shah, MD, found that medication errors could be reduced by 25% through the use of a length-based tool. In a recent policy statement by the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, the authors suggest that medication errors are still a threat with length-based tools, since the dosages noted on these tools are documented in milligrams rather than milliliters, which could contribute to calculation errors in the conversion of mg to mL. Standardizing drug concentrations and developing a conversion chart in the prehospital environment may be the only way short of an electronic conversion tool to prevent these errors.
MORE SUCCESSFUL IV STICKS
Instead of applying the usual thin elastic band to the upper arm for an intravenous stick, consider using a blood pressure cuff inflated to between 20–35 mmHg. This has several advantages:
- The pressure is measurable, and the risk of "blowout" from over- dilated, fragile veins is avoided.
- The patient is more comfortable, and there is no need to tighten, "pump" the fist or flick the skin.
- If the child is sick enough to require an IV, a BP should be recorded. EMS providers frequently neglect pediatric blood pressure checks, with the belief that they are not necessary in a child with an adequate peripheral pulse. This is only true in the child under 3 years of age. In a patient 3 years or older, blood pressure is a necessary and valuable assessment tool.
CHILDREN DON'T HAVE LESS PAIN THAN ADULTS
There are many misconceptions surrounding pain interpretation in pediatric patients. Recent science has concentrated on determining the reality of pain perception in children. A significant body of research suggests that children as young as six months have memory of painful experiences. Normal physiology supports this theory, since the limbic system and diencephalon, which are responsible for memory, are well developed in the neonate. It has been proven that unrelieved pain in children can have significant physiologic and psychologic consequences, which can include changes in activity level, appetite and sleep, and may impact hemodynamic stability.
Children have the same number and density of nociceptive nerve fibers (pain receptors) as adults, and can therefore experience pain in the same way. In addition, the neurochemical mediators that are often involved in the pain response are developed and functional. Finally, although children have a larger number of unmyelinated fibers, the overall distance that the nerve impulse needs to travel is significantly shorter than that of an adult, and pain is experienced. Unmyelinated fibers do not contain a myelin sheath, which is a cellular structure that surrounds a nerve fiber for the purpose of insulting the nerve to ensure that electrical impulses are contained and can move quickly across the nerve without interruption.
DETERMINING THE SEVERITY OF ABDOMINAL PAIN IN CHILDREN
Differentiating the severity of abdominal pain in children can be difficult. Two techniques can help determine whether a serious underlying disorder is present. During history-taking, ask the child what her favorite food is, and then ask if she would want to eat the food if you had some. Chances are, seriously ill children will not want to eat even their favorite food. On physical examination, ask the child to stand and hop up and down a few times. The ability to do this significantly reduces the probability of true peritonitis.
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