Pediatric Assessment

High Stress Situation l Child l In pain l Frightened l Guilty

High Stress Situation l Parent l Frightened l Guilty l Exhausted

High Stress Situation l Paramedic l Frightened l May over-empathize

High Stress Situation Who has to control situation?

Basic Points l Oxygenation, ventilation adequate to preserve life, CNS function? l Cardiac output sufficient to sustain life, CNS function? l Oxygenation, ventilation, cardiac output likely to deteriorate before reaching hospital? l C-spine protected? l Major fractures immobilized?

Basic Points l If invasive procedure considered, do benefits outweigh risks? l If parent is not accompanying child, is history adequate? l Transport expeditiously l Reassess, Reassess, Reassess

Patient Assessment l Priorities are similar to adult l Greater emphasis on airway, breathing

Patient Assessment l Limit to essentials l Look before you touch

Pediatric Assessment Triangle: First Impression l Appearance - mental status, body position, tone l Breathing - visible movement, effort l Circulation - color Appearance Breathing Circulation

Pediatric Assessment Triangle Initial Assessment l Appearance - AVPU l Breathing - airway open, effort, sounds, rate, central color l Circulation - pulse rate/strength, skin color/temp, cap refill, BP (  use at early ages) Appearance Breathing Circulation

Initial Assessment l Categorize as: l Stable l Potential Respiratory Failure or Shock l Definite Respiratory Failure or Shock l Cardiopulmonary Failure

Initial Assessment l Identify, correct life threats l If not correctable, l Support oxygenation, ventilation, perfusion l Transport

Vital Signs l Essential elements l Proper equipment l Knowledge of norms l Carry chart of norms for reference

Weight l Why is weight a pedi vital sign? l (Age[yrs] x 2) + 8

Heart Rate l Apical auscultation l Peripheral palpation l Tachycardia may result from: l Fear l Pain l Fever

Heart Rate l Tachycardia + Quiet, non-febrile patient = Decrease in cardiac output l Heart rate rises long before BP falls! l Bradycardia + Sick child = Premorbid state l Child < 60 l Infant <80

Blood Pressure l Proper cuff size l Width = 2/3 length of upper arm l Bladder encircles arm without overlap

Blood Pressure l Children >1 year old l Systolic BP = (Age x 2) + 80

Blood Pressure l Hypotension = Late sign of shock l Evaluate perfusion using: l Level of consciousness l Pulse rate l Skin color, temperature l Capillary refill l Do not delay transport to get BP

Respirations l Before touching l For one full minute l Approximate upper limit of normal = (40 - Age[yrs])

Respirations l > 60/min = Danger!! l Slow = Danger, impending arrest l Rapid, unlabored l Metabolic acidosis l Shock

Capillary Refill l Check base of thumb, heel l Normal < 2 seconds l Increase suggests poor perfusion l Increases long before BP begins to fall l Cold exposure may falsely elevate

Temperature l Cold = Pediatric Patient’s Enemy!!! l Large surface:volume ratio l Rapid heat loss l Normal = 37 0 C ( F) l Do not delay transport to obtain

Temperature l Measurement: Axillary l Hold in skin fold 2 to 3 minutes l Normal = F l Depends on peripheral vasoconstriction/dilation

Temperature l Measurement: Oral l Glass thermometers not advised l May be attempted with school-aged children

Temperature l Measurement: Rectal l Lubricated thermometer l 4cm in rectum, minutes l Do not attempt if child l Is < 2 months old l Is struggling

Physical Exam l Do not delay transport for full secondary survey l Children under school age: go toe to head l Examine areas of greatest interest first

Physical Exam After exposing during primary survey, cover child to avoid hypothermia!

Physical Exam: Special Points l Head l Anterior fontanel l Remains open until 12 to 18 months l Sinks in volume depletion l Bulges with increased ICP

Physical Exam: Special Points l Chest l Transmitted breath sounds l Listen over mid-axillary lines

Physical Exam: Special Points l Neurologic l Eye contact l Recognition of parents l Silence is NOT golden!

History l Best source depends on child’s age l Do not underestimate child’s ability as historian l Imagination may interfere with facts l Parents may have to fill gaps, correct time frames

History l Brief, relevant l Allergies l Medications l Past medical history l Last oral intake l Events leading to call l Specifics of present illness

History l On scene observations important l Do not judge/accuse parent l Do not delay transport

General Assessment Concepts l Children not little adults l Do not forget parents l Do not forget to talk to child l Avoid separating children, parents unless parent out of control

General Assessment Concepts l Children understand more than they express l Watch non-verbal messages l Get down on child’s level l Develop, maintain eye contact l Tell child your name l Show respect l Be honest

General Assessment Concepts l Kids do not like: l Noise l Cold places l Strange equipment

General Assessment Concepts l In emergency do not waste time in interest of rapport l Do not underestimate child’s ability to hurt you

Developmental Stages

Neonates l Gestational age affects early development l Normal reflexive behavior present l Sucking l Grasp l Startle response

Neonates l Mother, father can usually quiet l Knows parents, but others OK l Keep warm l Use pacifier, finger l Have child lie on mother’s lap

Neonates l Common Problems l Respiratory distress l Vomiting, diarrhea l Volume depletion l Jaundice l Become hypothermic easily

Young Infants (1 - 6 months) l Follows movement of others l Recognizes faces, smiles l Muscular control develops: l Head to tail l Center to periphery l Examine toe to head

Young Infants (1 - 6 months) l Parents important l Usually will accept strangers l Have lie on mom’s lap l Keep warm l Use pacifier or bottle

Young Infants (1 - 6 months) l Common problems l Vomiting, diarrhea l Volume depletion l Meningitis l SIDS l Child abuse

Older Infants ( months) l May stand, walk with help l Active, alert l Explores world with mouth

Older Infants ( months) l Intense stranger anxiety l Fear of lying on back l Assure parent’s presence l Examine in parent’s arms if possible l Examine toe to head

Older Infants ( months) l Common problems l Febrile seizures l Vomiting, diarrhea l Volume depletion l Croup l Bronchiolitis l Meningitis l Foreign bodies l Ingestions l Child abuse

Toddlers (1 - 3 years) l Excellent gross motor development l Up, on, under everything l Runs, walks, always moving l Actively explores environment l Receptive language

Toddlers (1 - 3 years) l Dislike strange people, situations l Strong assertiveness l Temper tantrums

Toddlers (1 - 3 years) l Examine on parent’s lap, if possible l Talk to, “examine” parent first l Examine toe to head l Logic will not work l Set rules, explain what will happen, restrain, get it done

Toddlers (1 - 3 years) l Common problems l Trauma l Febrile seizures l Ingestions l Foreign bodies l Meningitis l Croup l Child abuse

Preschoolers (3 - 5 years) l Increasing gross, fine motor development l Increasing receptive, expressive language skills

Preschoolers (3 - 5 years) l Totally subjective world view l Do not separate fantasy, reality l Think “magically” l Intense fear of pain, disfigurement, blood loss

Preschoolers (3 - 5 years) l Take history from child first l Cover wounds quickly l Assure covered areas are still there l Let them help l Be truthful l Examine toe to head

Preschoolers (3 - 5 years) l Common problems l Trauma l Drowning l Asthma l Croup l Meningitis l Febrile seizures l Ingestions l Foreign bodies Child abuse

School Age ( years) l Able to use concepts, abstractions l Master environment through information l Able to make compromises, think objectively

School Age ( years) l Give child responsibility for history l Explain what is happening l Be honest

School Age ( years) l Common problems l Trauma l Drowning l Child abuse l Asthma

Adolescents l Wide variation in development l Seeking self-determination l Peer group acceptance can be critical l Very acute body image l Fragile self-esteem

Adolescents l Reassure, but talk to them like adult l Respect need for modesty l Focus on patient, not parent l Tell truth l Honor commitments

Adolescents l Common problems l Trauma l Asthma l Drugs/alcohol l Suicidal gestures l Sexual abuse l Pregnancy