Beyond the Basics: Pediatric Assessment

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Pediatric Assessment (PDF)Valid until July 3, 2006

More than 20,000 pediatric deaths occur each year in the United States. This disturbing number validates how important it is that EMS providers are educated to effectively assess and manage the critical pediatric patient. Providing the best care possible can only be achieved by obtaining an appropriate history, coupled with an accurate physical exam. EMS providers must be capable of identifying any and all immediate or potential life threats in a child.

Airway Anatomy & Physiology
It is important to identify differences between adult and pediatric anatomy and physiology. The anatomical and physiologic variations between adults and children can cause confusion if the EMS provider does not fully understand these differences.

One of the most obvious anatomical differences between an adult and child is the tongue. The pediatric tongue is larger than the adult in relation to the amount of free space in the oropharynx. The large tongue creates a significant probability for airway occlusion and leaves little room for airway swelling. The size of the tongue is thought to be one explanation for why children are obligate nose-breathers: breathing through the nose is easier because it provides a direct path for airflow without concern for any obstruction that the tongue may cause.

The pediatric trachea is much more pliable and smaller in diameter than the adult and has immature tracheal rings. The increased pliability of the trachea can be troublesome in the pediatric patient because hyperextension or hyperflexion of the neck may lead to complete or partial occlusion of the airway. The small diameter of the trachea allows for only a minimal amount of swelling before significant compromise of airflow occurs.

The pediatric epiglottis tends to be large and is more u-shaped or oblong, making it more difficult to control when attempting intubation. There are a variety of practices related to pediatric intubation, including the preferential use of a straight (Miller) blade versus a curved (McIntosh) blade. The reason for this preference is attributed to the unique shape of the epiglottis: The curved blade fits into the vallecula and indirectly lifts the epiglottis from the glottic opening, whereas the straight blade is inserted under the epiglottis and directly elevates it for visualization of the vocal cords. This allows for better control of the epiglottis. The long epiglottis can easily flop down around the curved blade and cause visual obstruction of the glottis and vocal cords.

The position of the adult larynx is at about the level of the fourth or fifth cervical vertebrae; the pediatric larynx is at about the level of the first or second cervical vertebrae. If the pediatric larynx were lower, children would aspirate food into the trachea as they swallow. This is an important anatomical airway consideration, since the higher larynx is more anterior.

The mainstem bronchi in young children have less angle than in adults. As a result, aspiration can occur in either the left or right mainstem bronchi. As children grow, an increase in chest diameter causes the angle of the left bronchus to increase as well.

Red Flags in Pediatric Assessment
There are several clinical signs that must be considered when assessing a sick child. If any of the following signs are present, aggressive intervention should be employed as quickly as possible to prevent the child from going into cardiopulmonary arrest.

• Respiratory rate greater than 60
• Significant hemorrhage
• Respiratory distress or failure
• Significant trauma
• Nasal flaring
• Alterations in mentation
• Uncorrected noisy respiration
• Seizures
• Cyanosis
• Fever or history of fever with a global rash
• Mottling
• Heart rate greater than 180 bpm
• Pallor
• Heart rate less than 60

Cardiovascular Anatomy and Physiology
Although the pediatric and adult heart share identical anatomy, several important distinctions need to be made between the adult and pediatric cardiovascular systems.

First, the adult heart increases its stroke volume by increasing inotropy (strengthening contractions) and chronotropy (increasing heart rate). In contrast, the pediatric heart can only increase chronotropy in an attempt to increase stroke volume. The pediatric heart has low compliance as it relates to volume; therefore, it cannot compensate well by increasing stroke volume. Consequently, heart rate should be seen as a significant clinical marker when monitoring cardiac output in the fetus, neonate and pediatric patient. When the pediatric patient becomes bradycardic, it should be assumed that cardiac output has been drastically reduced. Bradycardia is most commonly caused by hypoxia. Bradycardia may be an early sign of hypoxia in the neonate; however, it is an ominous sign of severe hypoxia in the infant and child.

Structural Variations
The bones in young children are not completely calcified and tend to be flexible. Children's ribs are more horizontal than they are rounded, as seen in adults. The horizontal nature of the ribs provides for little leverage to increase the anterior and posterior diameter of the chest. This does not facilitate the degree of lift that is necessary to increase the volume of air within the chest when it is needed most. In addition, younger children have less-developed accessory muscles, making it more difficult to increase the strength and depth of ventilations.

When looking at a chest x-ray, it is easy to appreciate the relative amount of space the heart occupies in the chest of a child. The relationship between heart size and thoracic cavity size helps to explain why children have less pulmonary reserve than adults. Children have less ability to increase volume within the lungs, because the lungs are only capable of expanding to the degree there is space to expand; the heart occupies much of the thoracic cavity.

The pediatric abdominal cavity is small and has large organs compressed within it. A significant problem with the overcrowding that occurs in the abdomen is that it has a negative effect on the compensatory mechanisms of respiration in children. Children rely heavily on rate of respiration to compensate for respiratory difficulty because they are unable to increase the depth of respiration due to the inability of the diaphragm to move farther downward against the compacted abdomen. Conversely, adults can increase rate and depth of respiration when they experience respiratory difficulty.

Physiologic Variations
One of the first things to remember when dealing with pediatric patients is that the pediatric body surface area-to-volume ratio is four times that of an adult, while its heat production is only one-and-a-half times as high. This variation predisposes the pediatric patient to a greater risk for accidental hypothermia that can easily result in significant physiologic compromise. Additionally, the pediatric patient's muscle tone may be immature and, as a result, cannot effectively induce muscular shivering as an effective mechanism for preserving heat to the body core. Compounding this heat production and maintenance concern is that these patients generally have smaller amounts of adipose tissue, which contributes to poor insulation and additional difficulty in maintaining core body temperature.

Infants and small children are also at a greater risk for developing acute hypoglycemia because their livers are underdeveloped and they typically have decreased glycogen stores. The decreased glycogen stores, coupled with an increased metabolic rate resulting in the use of large quantities of serum glucose, makes the pediatric patient prone to hypoglycemia. Stress may induce hypoglycemia in the pediatric patient. A bedside glucose level should be evaluated in all infants regardless of the diagnosis.

A General Approach to Pediatric Assessment
Approach to the pediatric patient varies with the patient's age and the nature of illness or injury. It is critical that EMS providers be cognizant of the emotional and physiological needs of a child throughout the assessment. It is equally important to identify the needs of the child's family members. In this stressful environment, family members will be trying to find the cause of injury or illness in their child and may be unruly when the answers they seek are not available or are contrary to what is expected.

In many pediatric scenarios, EMS providers tend to rely on family members as their primary historians. However, as children become older, they may be as good or better than their caregivers at providing an accurate medical history. Although you should attempt to collect the history from children who are four years of age or older, older children are typically better at localizing pain or explaining their symptoms.

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.

Initial Assessment
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.

Airway Assessment
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
  
• Obesity/Obstruction
  
• Age (greater than 55)
  
• No teeth
  
• Stiffness

Mask seal
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.

Obesity/Obstruction
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
Age is not a factor in pediatric airway management.

No teeth
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
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.

Breathing Assessment
Normal respirations in an infant can be irregular and, as a result, respiratory rates should be assessed over a minimum of 30 seconds, but ideally 60 seconds. In adults, we often have a tendency to evaluate respiratory rates for 15 seconds and multiply those rates by 4. The variability of respiration in infants may not produce an accurate rate when only observed for 15 seconds. It is important to note that the variable rate of respiration in infants may include cessation in breathing for up to 20 seconds. Anything greater than 20 seconds should be considered abnormal and will require intervention.

One of the most common techniques for assessing the lungs is to determine lung sounds by auscultation. Auscultating lung sounds in a child ideally should be conducted in a relatively quiet environment and take into consideration that the child has a small and thin chest wall. Auscultate lung sounds in the midaxillary (below the armpits) region to ensure that referred breath sounds (sounds that can be transmitted from one side of the chest to another) are not heard. Hearing referred breath sounds is possible because a thin chest wall is capable of transmitting sounds easily.

In addition to lung sounds, it is imperative to determine the depth of respiration to ensure the child is maintaining an adequate tidal volume. Remember that the work of breathing that was identified in the PAT should be re-evaluated regularly throughout transport to make certain the child has not decompensated.

Pulse Oximetry
The use of pulse oximetery in children is highly recommended. Pulse oximetry readings can be used to monitor and document saturation readings over time and to make a possible correlation to improvements after interventions or worsening of the patient's condition. Caution should be taken when pulse oximetry is used for anything other than trending patient compensation or response to therapy.

A pulse oximetry reading of greater than 94% is generally adequate. If a child cannot maintain saturations above 94% on room air, he is in significant distress and will require supplemental oxygenation. If the saturations stay below 90% on a non-rebreather mask, this child is not getting enough oxygen and will require assisted ventilations. EMS providers must remember that a child may still be sick despite adequate pulse oximetry readings. Treat the patient, not the monitor. If the child looks sick, he likely is sick and will require intervention.

Capnography
Capnography is most useful when quantitative and graphic readings are available, as in continuous waveform capnography. This form of capnography allows for continuous airway and ventilation monitoring. It has been found to be especially useful during CPR. At the onset of cardiac arrest, carbon dioxide levels drop far and fast. Despite cardiac arrest, the carbon dioxide levels begin to rise with effective CPR; even more amazingly, they return to near-normal levels with a return of spontaneous circulation (ROSC). Clinical studies have proven that end-tidal CO2 levels have been predictive of cardiac output and coronary perfusion pressure (CPP). As such, it can be deduced that since ETCO2 can determine cardiac output and CPP, it can also effectively measure compression effectiveness during CPR.

In the prehospital environment, one study suggested that children are at a much greater risk for accidental endotracheal tube dislodgement (between 16% and 25% according to Gausche, et al.). It may be easier to identify a dislodged tube in children than in adults because of their sensitivity to hypoxia, but it may still be difficult. As a result of this statistic, there have been recommendations to make the use of continuous waveform capnography a staple of assessment in pediatric airway management instead of an optional tool. It is not a sin to have a misplaced endotracheal tube; the sin is not identifying it.

Circulatory Assessment
Pediatric heart rates are variable. Pulse points are no different in children than they are in adults, but there are some differences in the way these pulses are evaluated. The small anatomy of children, coupled with the lower palpable magnitude of pediatric cardiac output, makes palpation of pulses in certain anatomical regions impossible, or extremely difficult. In small children, it is recommended that peripheral pulses be obtained at the brachial artery (inside of the bicep) and central pulses be obtained at either the femoral or carotid arteries. If no pulses can be palpated, consider auscultating an apical pulse using a stethoscope. If a heartbeat can be heard, the child has a pulse; however, the presence of a pulse does not automatically indicate adequate perfusion.

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 do; therefore, their capillary blood flow is very responsive. Just as in the adult patient, environmental factors like cold ambient temperatures can influence capillary refill times. For this reason, capillary refill time should be assessed closer to the core in areas like the kneecap or forearm. Normal capillary refill time is less than two to three seconds.

Disability
The AVPU scale is a universally accepted method for determining the degree of mentation in both adults and children. An additional method of determining mentation in a noncommunicative child is the TICLS (pronounced tickles) scale (Table I).

A final method used for determining mentation is the pediatric Glasgow Coma Score or PGCS (Table II). It is important to note that the standard GCS model must be modified in the noncommunicative child.

Summary
Some children, regardless of what is done for them, will get sick and die. Fortunately, this is more rare than regular. An EMS provider who appropriately assesses a sick child with a potential to survive will be able to identify life-threatening conditions and manage those conditions. The most common cause of pediatric death is hypoxia. A hypoxic child without proper intervention will ultimately experience cardiovascular collapse and eventually death.

Most healthy children have no difficulty in maintaining normal cardiovascular function until and unless they become extremely hypoxic. EMS providers must understand that the most effective management processes require an understanding of why children present in the way they do. If an assessment is not thorough and accurate, a child may continue to deteriorate. Assessment is the key to pediatric management.

CEU Review Form
Pediatric Assessment (PDF)Valid until July 3, 2006

Bibliography
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William S. Krost, BSAS, EMT-P, is an operations manager and flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in Toledo, Ohio, and a nationally recognized lecturer.

Joseph J. Mistovich, MEd, NREMT-P, is a professor and the chair for the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.

Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, Maine, and a faculty member at Southern Maine Community College. He is the author of several EMS textbooks and a nationally recognized lecturer.