At the conclusion of this thi s chapter you should be able to: 1. 2. 3. 4. 5.
Discuss the age differences affecting the assessment of pediatrics Discuss the pediatric assessment triangle Discuss Discus s the C UPS assessment for establishin establishing g priorities List the elements of the pediatric focused and physical exam Discuss Discus s the importance of proper prehospital documentation of patient assessment
Case Study You are dispatched dispatched to a rural clinic to transport a mother and her 2 year old child to a pediatric hospital. Upon arrival you find the mother and child waiting in the reception room. The child appears to be sitting comfortably but you y ou notice that the child is staring blankly into space. You greet the mother and child and identify yourself. You notice that the child is oblivious to your presence. The doctor on hand says that the child was reported to have been ill for the last week with vomiting and diarrhea. The doctor has already establish established ed an I V line using a butterfly needle in the child's scalp. The doctor says that he had great difficu difficulty lty in finding a suitable vein. The doctor says that he administered 200ml of D5W with no effect. Your first impression is not a good one, you Your yo u immediately be gin your initial assessment assess ment taking note that the child has an altered me ntal status. The child's breathing is regular but the pulse is weak and a nd rapid (you can barely feel the child's radial and pedal pulses pulses). ). The child otherwise appears to be well per fused. fused. You decide to transport immediately. En route to hospital you put the child on supplemental oxygen. The child's pulse oximetry 95%capillary and air entry to3the lungs is equal equ al and clear bilaterally. The is child's refill is seconds. You administer an additional 200ml of fluid (based on the doctor's direction). You are not able to obtain a blood pressure although the distal pulses are still present. You assess the child's cardiac rhythm - a sinus tachycardia with a pulse rate of 150. You gently pinch the back of the child's hand to test the turgor of the skin and it remains significantly tented for at least a few seconds. You reassess reassess the child's mental status and the child seems to be a little more aware of it's surroundi surroundings. ngs. Using the CUPS assessment you decide that the child is uns assessment unstable table due to the a altered ltered mental status and severe dehydration. You ask you partner to radio the assessment information to the receiving hospital. You ask the mother for the child's sample history and additional pertinent history history.. Nothing is out of the ordinary except for the fact that the child child has been vomiting and had diarrhea for the past week with very little fluid intake to replace what was lost. It was only when the child st stopped opped crying and began to look "dazed" that the mother decided to take the child in for a check up. Upon arrival at the hospital you hand the child over to the receiving staff along with your documented asses assessment sment findings. This case study study highlights the fact that you are not always alway s able to determine exactly what is wrong w with ith a patient. You must simply go through the numbers and intervene as necessary as you proceed through your assessment assessment,, and provide prov ide rapid transport to the nearest most appropriate appropri ate medical facility. Introduction Children are not simply small adults; the physiologic physiological, al, em emotional otional and psychological differenc differences es as compared to adults are profound. When faced with an injured or ill child, you may find yourself experiencing a great deal of fear, fear, uncertainty, uncertaint y, lack of confidence and reserve. This is generally attributed to heightened emotions and lack of preparedness and experience when dealing with pediatric patients. Approach to Pediatrics Gaining the trust of the child and parents is essential; essential; failure to do so will make assess assessment ment of the child difficult if not impossible and may eve n worsen the child's condition. condition. It should be kept in mind that the child will most likely be frightened by the following: 1. The illness or injury 2. The response of the child’s family mem bers to the child's illness or injury
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3. The presence of complete strangers (you and your crew) 4. The fuss and commotion going on around him Children pose the following unique challenges to rescuers: Lack of communication – children may not be able to speak or properly express what is wrong. Response to illness/injury illness/injury – children are more like ly to panic at even the slightest injury let alone major trauma or illness. The child may be inconsolable which increases increases the anxiety of both rescuers and family mem members bers alike. Response of family members mem bers – parents, child minders and family members may be beside themselves with an array of various emotions as a result of the child’s inj injury/illness. ury/illness. General Considerations When Dealing with Pediatrics 1. 2. 3. 4. 5. 6.
Remain calm Stay at eye level with the child Make yourself known to the child in friendly and simple terms. Be cheerful and smile. Be patient with the child Be gentle when examining ex amining the child
Age Differences Affecting the Assessment of Pediatrics The assessment and treatment of children as well as a s the responses received are generally age specific. The different responses you can expect to receive are listed in the table below. Age Differences Affecting the Assessment of Pediatrics Under 6 months
6 months to 24 months
2 years to 3 years
3 years to 5 years
5 years to 12 years
Responds well to cooing sounds. Doesn’t mind clothing being removed or being examined. ex amined. Doesn’t mind strangers touching him. Should not be separated from parents. May respond to cooing sounds, sounds, may prefer to a soft toy or flashin flashing g light. Doesn’t mind clothing being being removed or being examined exam ined provided you do so in a calm, r eassuring and professional manner manner.. Perform toe-to-head survey. The “Terrible Two’s”, the child will say “No!” to almost everything. Likes familiar things so take along his favorite blanket or toy to hospital. Focus on the here and now; do not increase his anxieties by trying to ex explain plain to him things to come e.g. em ergency room procedures etc. Do not try to remove the child from the child's paren parents. ts. Obtain and maintain the child’s confidence confidence or the examination exam ination will get ver y difficult. Perform toe-to-head survey. Unless very scared they are generally cooperative. May negatively associate medical personnel with pain or other unpleasantness. Give the child reassurance. Tell the child that it is all right to cry. Give the child information on what is going to happen en route to and at the hospital. Does not like the sight or blood injuries. May still be disturbed by the presence of strangers or removal from par ents. Are modest and do not like having their sexual parts exposed. Have a good ability to comm communicate unicate whic which h can help to allay any concerns. Likes to know what is happening and wants to be “treated like and adult”. adult”. Does not like the sight of blood or injuries. Give the child information on what is going to happen en route to and at the hospital.
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12 years to 18 years
Needs a great de al of rea reassu ssurance, rance, especially regarding how the injury/illness will affect their looks or abilities. Keep the adolescent informed at each step of the assessment. Treat the adolescent like an adult, but give them the same reassurances as you would a child.
Scene Size Up Scene size-up size-up remai remains ns the same as for adults with a few exceptions. If you know that the incident in involves volves pediatrics, you should mentally prepare yourself yo urself for the challen challenge ge ahead. As you approach the patient, you yo u should try to get an a n overall assessment of the patient. Some question questions s that you should ask yourself are: 1. 2. 3. 4. 5.
Is the child moving/conscious? Is the child lying in a peculiar position? Are there any obvious obv ious mechanisms of inj injury? ury? Is there any sign of massive bleeding? What does the child look like in general i. e. cyanosed, pale etc?
Based on the outcome of the above assessment, you should decide whether IMMEDIATE int interventions erventions are re quired, or if you should take a mor e relaxed approach a pproach to gain the child child's 's trust. It must be pointed at that the initial assessment assessment must be stopped as soon as a critical conditi condition on has been identified and the appropriate iinterventions nterventions should should be made.
Always take a moment to assess th the e child from a distance if possible.
The Pediatric Assessment Triangle An accepted standard of pre-hospital pediatric care is the Pediatric Assessment T Triangle. riangle. All three of the components are interdependent. interdependent. The three components are: Appearance 1. What is the child's mental status? 2. How is the child's muscle tone? 3. In what position is the child lying? Breathing 1. Is there visible v isible evidence that the child is breathing? 2. Is the child having difficulty in breathing? Circulation 1. Does the child show any signs of poor perfusion e.g. cyanosis or pale skin 2. Is there any evidence ev idence of excessive bleeding? Initial Assessment Using the information gathered from your y our First Impression, a complete Initial Assessment must be undertaken. This assessment assess ment must be done in far greater detail than the first impression. The purpose of the initial assessment is to identify life-threatening conditions conditions and treat them accordingly accordingly.. The entire initial assessment should take less than one minute (excluding any critical interventions that need to be made). Assessing Level of Consciousness If the child was mov ing around and interacting with its environment during the First Impression you can most often move straight to the next step (Airway). If I f the child was not moving or appeared unresponsive gently shake the child to determine the leve l of responsiveness. Communicating with a child to obtain a history can prove very difficu difficult lt if the parents or guardians are not present or incapacitated. incapacit ated. Obtaining a history is basically impossible with a neonate or infant whose communication communication abilities are not yet developed (there is nothing more disconcerting than a child screaming blue murder while you, a complete stranger stranger,, are prodding and poking). AVPU During the First Impression you would have determined whether the child was alert or not. During D uring the initial initial
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assessment you use the AVPU scale to further assess the mental status of the child. The AVPU scale fortunately works as well for pediatrics as it does for a adults dults with the only exception that the severity of the child's condition condition between the different levels is far greater than with adults. Anythi Anything ng other than "Alert" should be considered a grave sign in a pediatric patient. A V P U
The The The The
child is alert, opening its eye s looking around, crying, moving its limbs spontaneously. spontaneously. child responds only to Voice. child responds only to painful stimulus. child is unresponsive.
Interventions For Children with a Decreased Level of Consciousness Children with a decreased level of o f consc consciousness iousness are at great risk for airway compromise or respiratory difficult difficulties. ies. Both airway and re spirations s should hould be closely monitored. The minimum level of treatme nt is the administrat administration ion of supplemental oxygen. Additional airway support and assisted assisted ventilations may al also so be required. Airway A child's airway has significant anatomical differences to that of an adult. The child's airway is shorter, narrower, softer and very susc susceptible eptible to dama damage ge or infection infection.. A child's airway should never be extended to past the "sniff "sniff the morning breeze" position as this will cause the child's airway to "kink" and become o obstruc bstructed. ted. Rescuers should be careful where they place their hands as even the slightest pressure can cause obstruction of the child's airway. In relation to an adult, a child has a very large tongue that c can an easily cause airway obstruction by flopping backward in the throat should the child be in a supine position. A child's mouth should be v isually inspected WITHOUT placing any objects in the child's mouth. The child’s airway can be classified as either patent and maintainable using basic airway positioning techniques, techniques, or not maintainable without intubation intubation or foreign body rem removal. oval. If a child has an altered level of conscious consciousness ness as detected during either the first impression or AVPU score, an immediate assess assessment ment of the airway must be performed. During the assessment assessment you m must ust make a classif classification ication of the child's airway as mentioned m entioned in the previous paragraph: patent and maintainable or not maintainable without intubation/foreign intubation /foreign body rem removal. oval. The following steps should be per formed during this part of the initial assess assessment: ment: 1. Listen for air movement and look for any chest or abdominal movement movem ent 2. Feel for air movement movem ent from the child's mouth 3. Be aware and take note of any abnormal noises su such ch as gurgling, snoring and stridor stridor.. Airway Interventions If the child has no sign (or very little signs of) air m ovement, attempts to open the airway must be made immediately. imm ediately. An obstructed obstructed airway can be the result of either poor airway positionin positioning g or an obstruct obstruction. ion. If the child is unconscious unconscious or unable to m maintain aintain an open airway: Position the airway using the modified jaw thrust or the head-tilt chin-lift. If this is not successful then try airway adjuncts adjunct s such as naso- or oro-pharyngeal tubes. Endotracheal intubation may be required in some cases. If the child has a complete com plete airway obstruct obstruction: ion: Attempt to open the airway using the modified jaw thrust or the head-tilt chin-lift. If this is not successful suction any visible secretions from the patient's mouth and attempt to provide assist assisted ed ventilations with a bag-valve mask with supplemental high high-concent -concentration ration oxygen. The use of Magill forceps or intubation may be required. Should all attempts to open the child's airway fail, a needle cricothyrodotomy should be performed according to local protocol. If the child has a partial partia l airway obstruc obstruction tion (with accompanying gurgling, stridor or snoring sounds): Attempt to open the airway using the modified jaw thrust or the head-tilt chin-lift, or assist the alert child in maintaining a position that is most comfortable for the child. If there are any gurgling soun sounds, ds, visible blood, secretions or vomitus the airway must be suctioned suctioned or aspiration may occur occur.. Breathing Breathing assessment assessment follows on directly from the airway assess assessment ment described above. The assessment assessment of breathing includes:
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An evaluation of the efficiency of the child's respirations i.e. rate, r hythm, depth and effort Auscultation of breath sounds Assessment Assess ment of skin color e.g. pink, pale or cyanosed Use of pulse oximetry Evaluation for any trauma to the chest The steps to follow to adequately assess breathing are: 1. Assess the the adequacy of the child's respiratory rate. To do this count the number of time the chest or abdomen rises and falls during a 30-second period and multiply that figure by two to get the rate/minute e.g. a count of 35 respirations in 30 30-seconds -seconds would work out to 70 respirations per minute (35 x 2 = 70). Normal values for a child's respiration rates are:
Neonates (up to 7lbs)
1 month to 1 6 to 10 2 to 6 years year years (from 22 to (from 7 to (from 44 to 44lbs) 22lbs) 75lbs) 20-40
10 to 18 years (from 75 to 110lbs) 15-20
If the child's respirations are outside of the above ranges it means that the child is not receiving sufficient sufficient oxygen or dischargin discharging g sufficien sufficientt carbon dioxide. 2. Assess the depth of the child's respirations This is an indication of the volume of air being m moved oved during respiration. Even if a child's respiration rate is normal, a respiratory depth that is very shallow is considered to be inadequate respiratory effort that will require intervention. 3. Assess the the child for signs of increased respiratory effort Signs of increased respiratory effort include: Retractions on inhalation inhalation - where the skin appears to pull iin n into the sternal notch, above the clavicles, between the r ibs (intracost (intracostal al retractions) or below the ribs (subcost (subcostal al retractions) Nasal flaring - a widening of the nostrils in infants infants and toddlers to allow more air a ir to enter the airway Bobbing head - the head lifts and tilts back on inhalation and falls forward on exhalation. 4. Assess the child's breath sounds First listen for sounds that are audible without the use of a stethoscope. Such sounds are a sign of increased respiratory effort. Place a stethoscope on each of the mid-axillary m id-axillary llines ines (beneath the armpits) and compare the sounds between the left and right lungs (the sounds should be the same). The stethoscope should not be placed at the nipples as the small size of the child's chest may cause soun sounds ds to be transmitted from one side of the chest to the other. Listen for abnormal breath sounds. Abnormal breath brea th sounds include: include: Grunting - a whining or "uh" sound on expiration. Wheezing - either a high- or low-pitched soun sound d heard on ex expiration. piration. Expiratory w wheezing heezing is usually usually a sign of bronchoconstriction Stridor - also a high- or low-pitched sound that is heard on inspiration. Stridor is usually a sign of an obstructed airway. Rhonchi - a sound heard when the airways are blocked by thick fluid or muscle m uscle spasm. spasm. Rhonchi is rumbling sound that is clearer on expiration and coughin coughing. g. Crackles/Rales - this is a fine, bubbling or crackling sound is most often heard on expiration but may also occur on inspiration. Crackles is a sound of fluid build up in the alv alveoli. eoli. Gurgling - this is a coarse bubbling sound that is heard on both inspiration and expiration. Gurgling is a sign of liquids in the airway. Suctioning is required. Identifying one or more of the above sounds (if they are present at all) will give you a much m uch c clearer learer picture of the child's condition. The most dangerous of all the sounds is actually no sound at all. You should at least hear normal breath sounds. sounds.
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"A silent grave awaits a silent chest" - Nancy L. Caroline 5. Assess the the color of the child's lips, tongue and buccal mucosa mucosa - Normally these are pink in color color.. Pale o orr blue color is a sign of hypoxemia which is caused by respiratory failure. Poor oxygenation ox ygenation may also cause decreased circulation which which will cause the skin to be pale. 6. Assess the the chest for life-threatenin life-threatening g injuries - C heck for chest injuries that will compromise the child's respirations and require immediate im mediate me dical intervention e.g. tension pneumothorax, open pneumothorax (sucking chest wound), flail chest or impaled im paled objects. 7. Perform pulse oximetry - Pulse oximetry must be performed on all infants and children whose mental, respiratory or circulatory situation is anything other than normal e.g. obstruc obstructed ted airway, respiratory failure/arrest or decreased level lev el o off consciousness. consciousness. The pulse oximeter provides a continual measurement of arterial oxygen oxy gen saturation (SpO2 (SpO2)) and the pulse rate based on an initial baseline reading. Arterial oxygen saturation is an indication of the efficiency efficiency of the lungs in oxygenating the blood. The following table shows the various ranges of SpO2:
Various Ranges of SpO2
Condition of child
From 95 95 to 1 10 00%
From 91 up to 9 95% 5% Mild Mild h hypox ypoxia ia
Less than 91%
The pulse oximeter reading changes frequent frequently ly and is to be used as adjunct only only.. A pulse oximeter oxim eter can never be used to determine if oxygen should be withheld - TREAT YOUR PATIENT PATIENT, not your yo ur equipment. Breathing Assessment Interventions If there is any a ny indication of respiratory comprom compromise ise the following steps should be followed: Administer high-flow high-flow oxy gen at high concentr concentrations ations for any sign of respiratory compromise such as: Variations in rate, depth or effort of bre athing Abnormal breath sounds Cyanosis For infants in respiratory distress deliver as close to 100% oxygen as possible. Assist ventilations ventilations with a bag-valve-mask and supplemental high-concentrat high-concentration ion oxygen in all cases where there is inadequate ventilation or respiratory failure/arrest. If present, treat bronchoc bronchoconstrict onstriction ion with supplemental oxygen and the a appropriate ppropriate medications. Seal any sucking chest wounds with a one-way valve type dressing (to allow air a ir to e scape the chest but not to enter it). If the child shows the signs of tension pneumothorax (distended neck veins, tracheal dev iation, anxiety, cyanosis, decreased lung compliance etc) the pressure inside the chest chest must be rel released eased by m means eans of a needle thoracocentesis. Cardiac arrest in children is generally secondary to respiratory failure and should always be closely monitored. m onitored. A child's breathing should not only be assessed by respiration rates alone, but the child's entire clinical picture should be taken into account. account. Such clinical sign signs s that should be considered are (in no par ticular order of priority): 1. 2. 3. 4. 5. 6.
Level of consciousn consciousness ess The child's agitation levels Cyanosis Cardiac status (BP, rate, rhythm and strength of pulse etc.) Mechanism of injury Chest auscultation auscultation (air entry should be equal bilaterally and clear)
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7. Child's history (asthma, wheezing w heezing etc) 8. Pulse oximetry (as ( as an adjunct on only) ly) Circulation To assess circulation the following should be evaluated: Peripheral pulses Central pulses Skin color, condition and temperature Capillary refill rate Evidence of severe external and internal bleeding 1. Check for major m ajor bleeding is present it must be controlled with direct press pressure. ure. 2. Check for central pulses pulses.. With infants the best central pulse to check is the brachial pulse; alternatively the femoral pulse can also be checked. In older children the carotid pulse is a go good od central pulse to assess. Once a pulse has been located determine the strength of the pulse. If the central pulse is absent or below 60 beats/minute with signs of hypoperfusion, begin external cardiac compressions compressions.. Weak central pulses can be indicative of late shock. 3. Once a central pulse has been located, continue to feel the central pulse and attempt to locate either a radial or pedal pulse. Com pare the two pulses, the rate, rhythm and strength should be the same (although the peripheral pulse will feel a little weaker than the central puls pulse). e). If you cannot locate the peripheral pulse or if it is significantly significantly weaker or irregular, inadequate peripheral perfusion is present whic which h is indicative of shock. 4. Calculate the pulse rate. Count the pulse rate for 30 seconds seconds and multiply that by two to determ ine the number of beats per minute. The table below shows the approximate pulse rates for various age groups.
Pulse Rates for Various Age Groups 1 month to 1 2 to 6 years 6 to 10 years 10 to 18 years Neonates year (from 22 to (from 44 to (from 75 to (up to 7lbs) (from 7 to 44lbs) 75lbs) 110lbs) 22lbs) 120-150
Concerns should be raised if the pulse rates are outside of the above values. If the child is being uncooperative and taking a pulse proves difficult, difficult, try and take the pulse rate by listening to the heart with a stethoscope. The best site for listening to the heart is between the child's nipple and breastbone on the left side which is directly directly over the apex of the heart. The formula for estimating the pediatric upper limit heart rate is: Rate = 150 - (5 x age in year s) e.g. a child of 6-years of age will have an estimated upper heart rate of 150-(5 x 6) = 150-30 = 120 beats per minute. 5. Check the skin color: Col Color
Cond Condiition of Chil Child d
Abnor m ma al / Poor per fu fusion
Abnorma ormall / Hy Hyp pox oxiia
Mo Mott ttle led d Abno Abnorma rmall / Sho Shoc ck If the child has dark skin, check the skin color at the lips, palms or soles of the feet. 6. Check the temperature of the skin. The child's skin should be warm. 7. Check capillary refill time. Press the skin on the forehead, chest, abdomen or the fleshy part of the palm. When released the color should turn turn from pale to the color of the surrounding area within 2 seconds. Press the area that is the warmest to ensure the best possible perfus perfusion ion to the are a being checked. 8. Only once the circulatory assessment has been completed should the blood pressure be taken. For children aged 3-years or younger y ounger the presence of a strong central pulse indicates adequate blood pressure and the presence of a strong peripheral pulse indicates a good blood pressure. I n children over 3-years of a age ge the blood pressure should only be me asured if time allows as the process may be time-consuming time-consuming..
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DO NOT delay transport to get a blood pressure reading.
Blood pressure should only be measured m easured after the respiration and pulse rates have been measured. Children are often agitated by the process of having their blood pressure taken which will artificially elevate the re spiration and pulse rates. Select an appropriately sized blood pressure cuf cufff (one that is 2/3 the size of the upper arm or thigh, the upper arm being preferable). The table below shows the average blood pressures for for the various age groups.
Average Blood Pressure
Blood Pressures for the Various Age Groups 1 month to 6 to 10 2 to 6 years 1 year Neonates years (from 22 to (up to 7lbs) (from 7 to (from 44 to 44lbs) 22lbs) 75lbs) 74/40
10 to 18 years (from 75 to 110lbs) 105/65
To estimate the lower limit of a child's systolic blood pressure pressure use the following formula: BP = (2 x age in years) + 70 e.g. a child that is 1010-years years old will have an estimated lower llimit imit systolic blood pressure of (2 x 10) + 70 = 20 + 70 = 90 systolic. 9. Assessing the child's cardiac rhythm. A child or infant that has any of the following should have continuous cardiac monitoring: Decreased level of conscious consciousness ness Abnormal airway assess a ssessment ment Abnormal breathing assess a ssessment ment Bradycardia Tachycardia Any sign of decreased pe rfusion The cardiac monitor should only be placed on the child once the initial assessment and required interventions have been performed. If any changes are noted in the child's cardiac rhythm, the changes should be correlated with any other chang changes es in the child's condit condition. ion. Dy Dysrhythmias srhythmias in children should only be treated if they comprom ise the child's breathin breathing g or circulation, or if the dysrhythmia is likely to degrade into a lethal rhythm e.g. ventricular tach tachycardia. ycardia. If a child's puls pulse e is absent, rapidly determine the rhythm to see if either pulseless ventric ventricular ular tachycardia or ventricular fibrillation is present, if so the child must be immediately defibrillated. Circulation Assessment Interventions If the child has a pulse of less than 60 beats per minute AND is receiving assisted ventilations - begin cardiac compressions. Do not begin cardiac compressions based on the absence of pulse alone as it is difficu difficult lt to locate a child or infant pulse (even at the best of times). A child requiring cardiac compression compressions s will show clear signs of inadequat inadequate e perfusion, will be unresponsive and will be unable to breathe adequately. Compressions should be performed at the following rates: For children under 8-years of age - one ventilation after every five compressions (pause during the the ventilation) until the child is intubated. Once intubated the pause is no longer required. For children over 8-years of age - two ventilations for every fifteen compressions (pau (pause se during the ventilations) until the child is intubated. intubated. Once the child is intubated switch to a ratio of one ventilation for every five compressions with no pause for ventilation. Children have excellent compensatory mechanisms and can maintain a normal blood pressure during the initial stages of shock. Once the compensatory mechanisms begin to falter falter,, they do so quickly and the child's conditi condition on can rapidly deteriorate. Signs of shock must be treated trea ted aggressively as they occur and the underlying cause of shoc shock k should be treated if possible. Treatment for shock includes: Administration of high-concentration high-concentration oxygen (this ( this should be done during the airway /breathing assessment assessment)) Control any massive m assive external bleeding. Children have far less blood than adults and even the smallest amounts of blood loss can have serious consequences. Unless contraindicated contraindicated by possible injury injury,, elevate the child's legs to above the level of the heart. Obtain IV access and administer a bolus of either ei ther saline or Ringer's Ri nger's lactate at 20mL/kg IIV V push. Repeat the fluid bolus up to three times if shock persists. DO NOT unnecessarily delay transport to set up an IV.
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Prevent body loss lo ss of body heat by wrapping the child in a space blanket. Small children are more susc susceptible eptible to loss of body heat than adults. Interventions for Dysrhythmias Bradydysrhythmias The most common commo n cause of bradycardia in children is hypoxia. First r eassess th the e child's airway and breathing to ensure that oxygenation and ventilations ventilations are adequate. If they are adequate and the child appears to be well perfused, no further action is needed. If the child shows signs of poor perfusion, the dysrhythmia should be treated as per local protocol e. g. administration of pharmacologic agents and the use of cardiac pacing. Tachydysrhythmias First it must be determined if the the dysrhythmia is a wide or a narrow complex. Wide complex tachydysrhyth tachydysrhythmia mia If the patient shows signs of cardio-respiratory insuffic insufficiency iency,, cardiover sion or pharm pharmocologic ocologic treatment may be required. Narrow complex tachydysrhyth tachydysrhythmia mia Determine if the rhythm is a sinus tachycardia tachycardia which will most likely be cause by easily correctable mild hypoxia or hypovolemia. I f the dysrhythmia is NOT a sinu sinus s tachyc tachycardia ardia the child's perfusion perfusion should be carefully reevaluated. If there ar e signs of cardio-respiratory insufficienc insuf ficiency y then either im immediate mediate cardioversion or cardioversion with pharmacologic agents should be performed. CUPS Assessment After the initial assessment is complete, do a CUPS assessment:
C - Critical
U - Unstable
Breathing is absent or child is having great difficulty in breathing.
Airway, breathing or circulation are compromised. Increased difficulty in breathing.
Bradypnea or Tachypnea. tachypnea with intermittent periods of apnea.
Child is cyanosed or pale.
P - Potentially Unstable
S - Stable
Child does not appear Child appears normal. to be in respiratory distress given your general impression but is susceptible to respiratory distress based on prior history history.. Normal to slightly elevated r espirations espirations..
Child may appear pale. Child is pink.
Normal re spirations spirations..
Child is pink.
Pulse oximetry is less than 90%
Pulse oximetry greater Pulse oximetry greater Pulse oximetry greater than 90% but less than than 95% than 95% 95%.
The CUPS assessment will help you y ou determine whether to do further assessment on scene or initiate urgent transport to the nearest m edical facility facility.. If the child is critical or unst unstable, able, perform only critical interventions (ABC's) on scene and transport the patient
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immediately. If the child is potentially unstable do the initial assessment and transport without delay. "Potentially unstable" includes a wide variety of conditions th that at are based upon the child being anythin anything g other than "Normal" even ev en though the child does not appear to be in distress. A dangerous mechanism of injury can class a child as potentially unst unstable able even iiff the child appears perfectly fine. If the child is stable, a complete focused exam and history can be completed before transport. As you progress with your treatment, it may be necessary to reassess your initial CUPS finding and react accordingly. accordingly. Reassessment As mentioned earlier, a child's cond condition ition can deteriorate rapidly. rapidly. Assessment should be ongoing until arrival at an appropriate facility hand toassessment. the emergency room staff staff.. Continuously monitor all elements elem ents of the init initial ial assessment assess ment medical as well the vitaland signs andover CUPS Vital Signs Vital signs are age specific, although it is extreme ly difficult if not impossible to accurately remember remem ber the vitals signs for the different age groups, it must be kept in mind that a 10 year old with w ith the vital signs of a 10 month old would be in a serious condition. condition. You should keep a copy of pediatric vital signs in your equipment bag. The table below summarizes the various vital signs for the different pediatric ages groups: Breathing, Breathi ng, Pulse and BP Age
up to 7 Neonates from 7 to 22 1 month to 1 year from 26 to 44 2 to 6 years from 44 to 75 6 to 10 years from 75 to 110 10 to 18 years
The above are merely a guideline. Always be sure to get the “big picture” and asses assess s the condition of a child as a whole. It is also impor tant to take the child’s s size ize into accoun account, t, some 4 ye ar olds are the size of 8 year olds. Pediatric Glasgow Coma Score The Pediatric Glasgow Coma Score is a modified ver sion of the Adult Adult Glasgow Com Coma a Score and takes into account the limited vocabulary and communicati comm unication on skills of pediatric patients. A copy of the Pediatric Glasgow Coma Score should be kept in the rescuers equipment bag as remem bering it while under stress will be unlikely unlikely.. Children over the age of 5 years can generally be assessed using the the adult Glasgow Coma Score. Eyes
Eye yes s o op pen s sp pont ontane ane o ou usly
Normal movement of limbs Smiling, cooing and (reaching out with hands appropriate crying for infants 4 5 and kicking feet) for infants 6 to normal speech for children to obeying of commands over 5 yrs for children over 5 yrs
Eyes open to voice (or shout)
Normal crying for infants to 3 confused/disoriented speech for children over 5 yrs
4 Localization of pain
Consolable crying for infants infants 2 to inappropriate words for children over 5 yrs
Normal flexion for infants 3 to withdrawal by flexion for 4 children over 1 yr
Grunting for infants to 1 incomprehensible noises for children over 5 yrs
Eyes open to painful stimulus
Eyes do not open
Abnormal Flexion (decorticate rigidity)
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Grunting for infants to incomprehensible noises for children over 5 yrs
No Verbal response
1 No m otor response
Abnormal Extension (decerebrate rigidity)
It should be noted than when recording a GCS it is not helpful to simply write down 12/15 or 4/15, the individual items should be noted as well e.g. Eyes - 3, Verbal - 2 and Motor - 5. The reason for this is that although one aspect of the child's GCS may impr ove, another may decline e.g. an initial assessment of the child's child's GCS revea reveals ls Eyes - 3, Verbal 4 and Motor 4 (totaling 11/15), 11/15), a few m minutes inutes later the ch child's ild's GCS is Eyes -2, Verbal -3 , Motor - 6 (totaling 11/15). 11/15). Although both GCS's are 11/15 the clinical significance of each is vastly different. Focused Assessment With seriously sick or injured pediatric patients init initial ial interventions and early transport are a pr iority iority.. Additional background information and history should not delay transport but should rather be taken en route to hospital if accompanied by the parents of the child. If there are suff sufficient icient personnel personnel on scene, one team m member ember can obtain a focused history while the other team members do the initial assessment and perform the necessary interventions. If the child's condition is urgent, the history taking must not delay the child's trans transport port to hospital. If the child is non-urgent a more detailed history of the child's condition can be collected. Typically Typically the history is obtained from the par ents but sh should ould the child be old enough they should be give n the opportunity to answer questions for themselves. SAMPLE History S
SIGNS & S SY YMPTOMS In pediatric cases it will probably be e asier to note signs as opposed to asking the child child what is wrong. The signs & symptoms part of the SAMPLE his history tory will include all the findings in the preceding assessments.
ALLERGIES This information information can be obtained from m edic alert bracelets or family m embers. Special note must be taken of any allergies to any medications.
MEDI CA CATIONS Medicine (prescription or otherwise) that the child has taken that day, or takes regularly. Again, this information information would have to be obtained from a family fami ly membe r, alternatively the information can be obtained from medicine bottles (do not waste time trying to determine what the child took).
PAS AST T ME MED DICAL ICAL HIST HISTO ORY A small child is unlikely to know a detailed medical history. T Try ry to establish wheth whether er the child has had previous hospitalizations, operations, complications and any serious underlying illnesses.
LAST MEAL At what time did the child last eat, what did the child eat (is it something the child normally eats), was it i t a regularly scheduled meal, has the child being eating normally?
EVENTS What caused the paramedics to be summoned to this patient? If the child is an asthmatic and has regular attacks, what is different this time that the paramedics were called?
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Once the SAMPLE history history has been completed, you should determine if any of the additional findings will alter the CUPS assessment and act accordingly. Additional history You should should also inquire into and take note of any injury or illness specific to: 1. Mental status Have there been any changes in the child's behavior or level of consciousnes consciousness? s? Has the child been them self lately? Has the child suffered any illness or injury that caused them to lose consciousness or be "dazed". 2. Airway Has the child suffered from an asthma attack a ttack or upper airway infections infections? ? Has the child ever had a tracheotomy? 3. Breathing Have there been any changes in the child's breathing patterns? Has the child ever stopped breathing? 4. Circulation If there is any exter nal bleeding and you yourself were not able to see the amount of blood lost, ask the parents to estimate the amount of blood lost in layman's terms. term s. Inquire as to whether the child has been vomiting or has had diarrhea, and for how long. Also make inquiries i nquiries into what the child's fluid int intake ake has been like lik e for the past few days. If possible try and determine how often the child has urinated. urinated. 5. Trauma Determine if the child has suffered any major trauma in the recent past e.g. unrestrain unrestrained ed motor vehicle collision, fall from significant height, height, pedestrian vehicle accident, fall from bicycle (helmet?) 6. Neurological history and developmental history Has the child suffered from any seizures? If so try and determine determ ine when, for how long, the frequency and the child's behavior before and after the seizures. Did the child have a fever prior to the seizure? 7. Fever Try to determine if the child's temperature has been taken tak en recently, recently, what that temperature was and how the temperature was taken i.e. oral, rectal or tympanic. tym panic. Did the child have any neurological changes during the fever. Find out child whatsuffered anti-pyretic were given to reduce the fever. Has the any medications serious infections? Has the child's doctor recommended any special care during a fever? 8. Poisonings If a child is known or suspected to have ingested or otherwise been exposed to a poison try an determine how the poisoning occurred, what the poison was, how much may have been ingested and whether any "home remedies" were given to the child for the poisoning. poisoning. Ask if the child has had any seizures, cramps, nausea, vomiting vom iting or changes in behavior Discretely try and determine whether w hether this was a suicide suicide attempt 9. Burns Determine the source of the burn e. g. fire, steam, electricity electricity,, chemicals Determine the location and ex tent of the burns on the child's body Carefully assess the child's mouth and nose for signs of inhalation burns. Ask if there has been any change in the child's mental status. 10. Near-drowning Find out how long the child was immersed. imm ersed. Was there any chance of spinal injury?
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Were any drugs or alcohol involved? Was CPR given to the child? 11. History for a Newborn Is the mother expecting multiple births? Is the delivery mor e than four weeks premature? Has the water broken? Was the fluid fluid discolored e.g. brown, gr een or bloody? Has the mother recently abused any substanc substances es e.g. narcotics, alcohol Has the mother gone for regular check check-ups? -ups? Are there any problems that have bee n anticipated? e.g. breached baby? If there is any history related to the above the appropriate interventions should be performed and once again the CUPS assessment assess ment should be r eevaluated. Physical Exam Head-To-Toe Survey and Toe-To-Head Survey If the child is facing a life-threatening condition do not delay transport or initial interve ntions to perform a physical exam. If it does iinterfere nterfere with the ongoing assessment of the child's ABC's the physic physical al exa exam m should be conducted en route. If the child's condition is not urgent the entire physical exam can be performed on scene. With infants and very young child always conduct conduct the head-to-toe survey in reverse, i.e. go from toe to head. This will help you gain trust and will most likely allow a llow you to complete the entire assess assessment. ment. During the assessment be alert for any DCAP-BTLS (deformities, contusion contusion,, abrasions, punctures, punctures, burns, tenderness, llacerations acerations or swelling).
Examine what is most painful LAST and what concerns the parents most FIRST.
Continually reassure the child during the exam and gain the child's trust. Encourage the parents to assist a ssist with the physical examination.
Contusions (bruising) Abrasions
Head Gently palpate the head and feel for any skull irregularities or soft, spongy areas. Feel for crepitus (bone crunching crunching sound). If any of the aforementioned are present the child should be considered critical.
In infants the "soft spot" should be carefully examined. A bulging soft spot with a Swelling history of trauma can indicate increased intracrani intracranial al pressure. A bulging soft spot with a history of o f fever can indicate meningitis. A sunken soft spot is an indication of dehydration. Eyes Assess the pupils, they should be PEARRL (Pupils equal and round and reactive to light). Both Assess pupils should be equal and they should constrict when a penlight is shined into them and dilate when the light is removed. Unequal pupil reaction with a history of trauma is a sign of potential brain damage. Look for ecchymoses (bruisi (bruising) ng) beneath the eyes which is a sign of base of skull fracture. If there is an injury to either o off the eyes, BOTH ey eyes es should be dressed. This helps reduce the movement of the eyes. Nose Check the nose for de formity or if there is any clear clear,, straw-colored fluid (CSF - cere bro-spinal fluid)or blood draining from the nose. I f you suspect CSF is leaking the child should be considered to be critical. Mouth Although Althoug h the mouth should be checked under airway and breathing, reassess for any soft tissue damage or dam tissue damaged aged teeth. Do not stick anythin anything g into the child's mouth. Assess Asses s the mouth for dry dryness ness which may be a sign of dehydration or hypovolemic shock. Ears Examine the ears for any leak ing blood or CSF CSF.. Ecchymoses behind the ears is a sign of base of skull fracture.
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Neck The child's trachea should should be m midline. idline. If the trachea is dev deviated iated to either side (a sign of potential tension pneuomthorax caused either by trauma or severe asthma) the child should should be immedia immediately tely reassessed for respiratory difficulty. Although difficult difficult to detect in smaller children, distended neck veins may present in the case of o f fluid accumulation in the pericardial sac. If no trauma has been sustained the neck should be gently assessed for any stiffness (meningitis). This accompanied with a history of fever may m ay put the child at risk for altered me ntal status status,, respiratory distress and shock. If trauma is susp suspected, ected, have cerv cervical ical spine support maintained while gently feeling the back of the neck for any tenderness, deformity or crepitus - all of which may indicated spin spinal al injury. If a cerv cervical ical spine injury is suspect suspected ed particular attention must be paid the child's respiratory status and motor reflexes. Chest Check both sides of the chest for DCAP-BTLS. Check for crepitus or abnormal movement of the ribs. Assess for for signs of respiratory distress if any of the above are a re present. Auscultate Ausc ultate the heart for any irregular or extra sounds e.g. murmurs, skipped beats, clicks etc Auscultate Ausc ultate the chest for breathing sounds over all the appropr iate points. Take note of any wheezing, Rhonchi or crackles. Make sure that the breathing brea thing soun sounds ds are equal bilaterally bilaterally.. If I f the sounds are unequal pneumonia, pneumothorax or tension pneumothorax may be present. Abdomen Check the abdomen for DC AP-BTLS AP-BTLS.. Use care when palpating the abdomen abdom en for tenderness. Take note of any guarding (the child stiffens the abdominal muscles). Reassess the child's circulatory status if guarding and/or tenderness is present. Reassess the child's breathing status if the child has been crying incessantly and the abdomen is distended. Children may swallow a lot of air when crying which resu results lts in the abdomen being distended. An abdomen swollen from swallowe d air is indicated i ndicated by an enlarged left upper quadrant where the stomach is situated. The enlarged stomach put pressure on the diaphragm making ma king it more difficu difficult lt for the child to brea breath. th. Pelvis Check the hip bones for DCAP-BTLS Check the pelvis for stability taking note of any abnorm abnormal al looseness or crepitus. If the pelvis is unstable, reassess the child for signs of shock. The mechanism of injury required to fracture a pelvis re quires significant significant force and a high index o off suspic suspicion ion for additional injuries should be maintained. Genitals If the child has any complaints in the genital ar ea, assess for DCAP-BTLS. Extremities Check radial pulses, capillary refill and war mth in all extremities. Absence of pulses and abnormally cool extremities indicate poor perfusion to that area especially if one limb is noticeably different to the other. In this case the limb may m ay be threatened and the child's cond condition ition is urgent and must be rapidly transported to hospital. Check motor func function tion and nervous reflex in all extrem ities. Check the extremities extremi ties for DCAP-BTLS Compare the extremities being exam examined ined to one another, another, take note of any difference or deformities. If there is any deformity, tenderness or ecchymoses the limb should be imm obilized. If the movement movem ent in the limbs is unequal, immobilize the limb and the spine. Unequal movement can occur as a result from the pain of trauma or muscle, nerve or brain damage. A child's bone is most likely to break at the point of the growth plates (near the joints). A fract fracture ure is almost always has accompanying ecchymoses. Back Check backtenderness, for DCAP-BTLS DC AP-BTLS. . ymoses or crepitus present th If therethe is any ecch ecchymoses the e child should be immobilized. If a spinal injury is already susp suspected, ected, the child's back should be checked when the child is being log rolled onto the spine board. Skin
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Check the skin for DCAP-BTLS In addition check the skin rashes, sores, inflammation or o r any o other ther abnormality. Check any area that the child complains is painful. Be alert for signs of child abuse (suc (such h as ecchymoses in unusu unusual al areas) o orr disease. IIff abuse is suspec suspected ted it must reported to the medical staff at the receiving hospital. Gently assess the turgor of the skin by pinch pinching ing a fold of skin to see if r emains "tented" when released. If the skin does remain rema in tented and does not "spring" back the child may be dehydrated. Also check for dryness of the mouth, sunken eyes or absence of tears when crying. A dehydrated child is at an increased risk for shock. Additional Pediatric Assessment Tools Length-Based Resuscitation Devices Remembering the various weights, vital signs, drug dosages and volumes of o f fluid for resuscitation for child children ren is an almost impossible task, especially when faced with the stress and pressures of a pediatric patient. A length-based resuscitation resusci tation device should always be used when drug interventions are required. The tape should be used as follows (always follow the manufacturers inst instructions ructions): ): 1. Place the child supine. 2. Measure the child from the top of his head to the heel of his foot. The red end of the tape with the arrow goes to the child's head. 3. The box that is at a t the heel of the child's foot shou should ld be used to e stimate weight and give IV fluid and drug doses. 4. If the heel of the child's foot falls on the line, use the box closest to the child's head to calculate doses i.e. use the box with the lesser weight. 5. The tape is waterproof waterpro of and can be disinfected. The Broselow Tape is a practical way to estimate the child's weight by me asuring his lengt length. h. The Broselow tape has precalculated doses of IV fluids and drugs for each weight range of the child. The tape also gives a good indication of the correct sizes of equipment to use. ALWAYS have a full pediatric resuscitation kit available as the size indicated on the tape may be too lar ge or too small (the tape provides a guideline only). Transport This is the primary goal of o f prehospital emergency care, to stabilize and safely transport the patient to th the e nearest most appropriate medical facility for definitive medical care. Children should not be carried in arms by either providers or parents if the child has traumatic injuries injuries that warrant spinal immobilization. If the child will require ongoing ventilations such as assisted assisted ventilations or CPR the child shou should ld be placed supine on a spineboard or stretcher. A child may be transported in parents arms if both the child and parent are safely restrained according to local transportation protocols, and the child's condition is not serious. Children are invariably comforted by the presence of familiar a adult dult faces, but shou should ld the parents be over ly distraught they should be transported to the hospital in a separate vehicle by a person who is in a sound enough c condition ondition to drive safely (in other wor ds don't let a distraug distraught ht parent get behind the wheel). All initial assessment findings findings should be forwarded to the receiving medical facility in order o rder to prepare the hospital staff for the child's arrival. Patient Records All your findings must be recorded and presented to the hospital staff upon your arrival. You Yourr patient documentation will provide valuable insigh insightt to the hospital staff on exactly which intervention interventions s or treatm ents need to be perform performed. ed. The documentation should should be free of pe rsonal opinions. All interventions and the patient's re spons sponse e to those interventions sh should ould also be recorded. The following is a general guideline on the information that should be included: 1. First impression 2. Findings during during the initial a assess ssessment ment and the interventions performed 3. 4. 5. 6. 7.
Findings from the focused history (if taken) Vital signs including including the times they we re taken Finding during the physical examination All treatments and the patient's response to those treatments All findings from reassessments, reassessments, as w well ell as rea reasons sons for any reassessments e.g. you noticed the skin color change