Pediatric assessment:
Don't let appearances fool you, pediatric patient's are not just “little adults”. The assessment of pediatric patients requires recognition of physiological and developmental differences through the adult and the child. Peds patient's present a challenge to the EMS provider because they don't typically present as dramatically as adults do, even in shock states, and they are able to compensate very well, without obvious signs, right up until they don't anymore. For this reason the assessment process has been adapted for paramedics when assessing individuals in this age range.
The official definition of a pediatric patient is anyone under the age of 18 years, however this is subjective, and a more appropriate definition would be: age >24 hours to onset of puberty (Neonates are a category unto themselves. For the purposes of simplicity, lets just say we are referring to a young child.
Physiological differences:
In children there are a few things that are markedly different than seen in adults. The most obvious is the size of the head, which is proportionally larger in relation to the body. It is because of this that children tend to strike their heads during falls. In addition to the size of the head, young children have a proportionally larger tongue in relation to the mouth than adults do. This means that it is a more significant mechanism of airway obstruction in unconscious states, or in the presence of angioedema. The epiglottis of a young child is “floppy” and U-shaped, making it an additional problem in the setting of airway management; particularly intubation. Also worth noting, infants are nose-breathers, so congestion or obstruction of the nasal passages can lead to significant respiratory distress.
The cardiovascular system in infants and young children is also slightly different than seen in adults. Cardiac output is rate dependent in these patients, as they lack the ability to increase stroke volume to any significant degree. For this reason, hypovolemic states can be a big problem.
Pediatric assessment:
In EMS we have adopted the Pediatric Triangle in order to assess young patients. This assessment is meant to occur “at the door” when you first visualize the patient. It allows for a clear picture of the child's degree of distress, and allows the paramedic to determine potential interventions that may be needed rapidly. The triangle consists of:
Appearance
Work of breathing
Circulation
Appearance: When assessing the pediatric patient, we first look at appearance. The mnemonic TICLS is helpful in observing general appearance.
Tone
Interactiveness
Consolability
Look or gaze
Speech or cry
Work of breathing: When assessing work of breathing, we want to look at positioning, use of accessory muscles, indrawing, nasal flaring, or head bobbing, all of which indicate respiratory distress. We also want to observe for central or peripheral cyanosis, and listen for adventitious sounds.
Circulation: We want to look for pallor, cyanosis, or mottling, and assess cap refill and peripheral pulse points. Note that the pulse varies by age of the patient, and you want to know the reference range for each. In patients in compensatory shock, tachycardia and pallor are typically early signs. Decompensation is typically indicated by alterations in LOA, hypotension, and in young patients, the trend toward bradycardia. Watch your shock index.
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