There are a few challenges to providing emergency care to pediatric patients, which is why effective communication with both the patient and their family members is critical to success. A child may or may not be able to tell you what is wrong, and the caregiver may be acting irrationally, but communication is the key. You also may need to care for the caregiver as well. Calming the parent will often calm the child.
Stages of development differ for a child. A child is in infancy for the first year of their life. They breathe about 30 to 60 breaths a minute and have a heart rate between 85 to 205 beats/min. In the first 2 months, they can sleep for up to 16 hours a day and respond mainly to physical stimulation and can be aroused from rest very easily. They may cry if certain basic physical needs must be met, such as food, warmth, and comfort. Every attempt should be made to identify why the infant is crying. They also exhibit the sucking reflex and start sucking when their lips are stroked. They can easily get hypothermia. During the 2 to 6 months, there is a strong sucking reflex, and they may follow a bright light or toy with their eyes or turn their head. Lack of eye contact could be a sign of serious illness. For 6 to 12-month-old infants, they are more exposed to physical dangers and choking. They may cry if separated from their parents and have a persistent cry, which can be a sign of serious illness. If possible, allow the parent to hold the child and do the painful process at the very end.
The next stage of development is the toddler, from the first year until they are at preschool age. They take between 24 and 40 breaths a minute and have a heart rate of about 100 to 190 beats per minute. In the first 6 months, from 12 to 18 months, the child begins to walk and explore the body, and there is an increased risk. They can speak four to six words. At 18 to 24 months, they can speak between 100 words. When performing an assessment on a toddler, if possible, take a doll or stuffed animal and show them the examination on the toy first. Allow toddlers to play with an object before examining them and involve the parent or caregiver.
The preschool-age child is in that group until they enter the school-age years. They breathe for about 22 to 35 breaths per minute, and the heart rate beats from 60 to 140 beats per minute. They have a rich imagination and cognitive illusion about how the injury happened. Always tell the child what you are going to do first. You can also make it a game, like you are a superhero breathing in oxygen.
School-age years are from when they enter school until adolescence. They breathe between 18 to 30 breaths a minute and have a heart rate of 60 to 140 beats per minute. They begin to understand that death is final, but understanding of what death is and why it occurs is still unrealistic. This may increase their anxieties about illness or injury. Ask the child if you can do the part of the assessment.
Adolescents breathe 12 to 16 breaths a minute and have a heart rate of 60 to 100 beats per minute. They can understand complex topics, and allow the adolescent to speak openly about any thoughts and concerns. Sometimes information may not want to be given in front of a parent. Find out some of their interests and get them talking.
The pediatric airway is smaller in diameter and shorter in length, the lungs are smaller, and the heart is higher in a child’s chest. The glottic opening (vocal cords) is higher and positioned more anteriorly (towards the front), and the neck appears to be nonexistent. As the child develops, the neck gets proportionally longer as the vocal cords and epiglottis achieve their anatomically correct adult position. There are less-developed rings of cartilage in the trachea that may easily collapse if the neck is flexed or hyperextended. A narrowing funnel-shaped upper airway compared to that of a cylinder-shaped lower airway. Be cautious when applying straps to a spinal motion restriction device because this may hinder full symmetrical chest wall expansion and thus limit tidal volume. The pulse rates differ between different age groups due to the size of the lungs. The head is larger, which makes it more susceptible to head injuries, most likely injured as a result of a fall. Internal organs, such as the liver and spleen, are more susceptible to bleeding and injury. The musculoskeletal system is more susceptible to fracture with stress due to growth. Soft spots in the head, known as fontanelles, are a useful assessment tool for issues such as increased intracranial pressure (bulging with a non-crying infant) or dehydration (sunken appearance). Easier sunburn and heat and fluid loss.
Remember TICLS when assessing a pediatric patient. Tone: first question is the child moving or resisting examination vigorously? Does the child have good muscle tone, or is the child limp, listless, or flaccid? Interactive: how alert is the child? How readily does a person, object, or sound distract the child or draw the child’s attention? Check ability to console and if the child can be consoled or comforted by the parent, caregiver, or EMT. Check look or gaze: does the child fix his or her gaze on a face, or is there a vacant, glassy-eyed stare? Speech or cry: is the child’s cry strong and spontaneous or weak or high-pitched? Is the content of speech age-appropriate or confused or garbled? Also consider the Pediatric Assessment Triangle, which is appearance, work of breathing, and circulation to the skin.
The Pediatric Glasgow Coma Score is eye opening, verbal, and motor. For an infant, eye opening is 4 open spontaneous, 3 open to speech or sound, 2 opened to pressure, and 1 for no response. For a child, eye opening is judged the same way. Verbal is different between an infant and a child due to the infant’s inability to hold a conversation. For an infant, verbal is 5 for coos and babbles, 4 for irritable cry, 3 for cries to pain, 2 when they are moaning to pain, and a 1 is no response. For a child, it is 5 for oriented conversation, 4 for a confused conversation, 3 when they are crying, 2 when they are only moaning, and a 1 for no response. Motor also differs between infants and children, with a child being closer to the adult version of GCS. Infants receive a 6 for normal spontaneous movement, a 5 for localized to pressure, a 4 when they withdraw from pressure, a 3 for abnormal flexion, a 2 for abnormal extension, and a 1 when there is no response. A child receives a 6 when they obey verbal commands, a 5 when they localize to pressure, a 4 when they withdraw from pressure, a 3 for abnormal flexion, a 2 for abnormal extension, and a 1 when there is no response.
Respiratory emergencies and management are another thing to be cautious of. Be concerned with pale, not always cyanosis. Always provide oxygen to a child in respiratory distress. Anxiety, agitation, or crying may increase the effort or work of breathing. Give nothing by mouth if the patient has severe respiratory distress, in case the patient’s condition deteriorates suddenly. For airway obstruction, consider infection as a possible cause if a child has congestion, fever, drooling, and cold symptoms. Upper airway obstruction—stridor. Lower airway obstruction includes wheezing. If you see signs of a severe airway obstruction, you must attempt to clear the airway immediately: ineffective cough (no sound), inability to speak or cry, increasing respiratory difficulty, stridor, cyanosis, loss of consciousness. If an infant is conscious with complete airway obstruction, perform up to five back blows followed by five chest thrusts. If a child older than 1 year is conscious, perform abdominal thrusts. Look inside the mouth to see whether the obstructing object is visible; if visible, try to remove it using a finger sweep motion. If they go unconscious, begin CPR.
Asthma is a condition in which the smaller air passages (bronchioles) become inflamed, swell, and produce excessive mucus. It is the leading chronic disease in children, and lower air passages are partially obstructed. Allow the child to assume a position of comfort in the parent’s or caregiver’s lap. A bronchodilator such as albuterol or with ipratropium via a metered-dose inhaler with a spacer mask device. A prolonged asthma attack is known as status asthmaticus. Administer oxygen, ventilate, and provide rapid transport to the ED. Asthma is very tiring; an exhausted pediatric patient may stop feeling anxious or even struggling to breathe. It may look as if the patient is recovering; however, he or she is at a critical stage and is likely to stop breathing.
Pneumonia is an infection of the lungs—secondary infection after a cold or ingestion of chemicals or submersion incident. Immunodeficiency patients are at increased risk for pneumonia, with diminished breath sounds or crackles. Particularly serious in infants—if wheezing, administer a bronchodilator if permitted. Croup (laryngotracheobronchitis) is an infection of the airway below the vocal cords caused by a virus. Typically seen in children between 6 months and 3 years. Easily spread, with hallmark signs of stridor and a seal-bark cough, indicating narrowing of the trachea. Croup responds well to humidified oxygen. Bronchodilators are not indicated for croup and can make the child worse.
Epiglottitis is an infection of the soft tissue above the vocal cords. It is worse in children because it can swell significantly and obstruct the airway. Bronchiolitis is a viral illness of newborns and toddlers, often caused by RSV. It is highly contagious and occurs in the first 2 years of life. Look for dehydration; infants may refuse liquids. Pertussis (whooping cough) is contagious—use precautions.
There are different ways to deliver oxygen to a child. Nonrebreather mask, nasal cannula, or simple face mask is used when respirations are adequate. Assisted ventilation is used when inadequate. Blow-by oxygen can be used for infants. Ventilation rate is 1 breath every 2 to 3 seconds. Watch for chest rise.
JumpSTART: if apneic and no pulse, deceased. If pulse but no breathing after 5 breaths, deceased. Decision points include walking, breathing, pulse, and AVPU.
When a patient has passed away, use the word dead. Speak at eye level, use the child’s name, acknowledge feelings, keep instructions simple, and offer support. Never say, “I know how you feel.”
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