Pediatric Assessment

Provena Regional EMS System July 2011 Continuing Education

PEPP
This continuing education lesson is drawn from a national program called PEPP Pediatric Emergencies for Pre-hospital Professionals Developed by the American Academy of Pediatrics

When dealing with sick kids there is a Core Dilemma: Sick? Not Sick? Not Sure?
A sick child demands immediate management and frequent assessments.

Pediatric Assessment: Which of These Patients is Sick?

2-week-old Fever, less responsive A/B RR 60, patent airway, belly breathing, SaO2 unobtainable C HR 160, skin pink, marbled centrally, hands and feet blue; radial pulse hard to palpate D AVPU eyes open, no eye contact, no vocalization, moves extremities sporadically 10-year-old Fever, less responsive A/B RR 60, patent airway, belly breathing, SaO2 unobtainable C HR 160, skin pink, marbled centrally, hands and feet blue; radial pulse hard to palpate D AVPU eyes open, no eye contact, no vocalization, moves extremities sporadically

 The assessments made on the 2 week old are all normal assessments

The assessments on the 10 year-old reveal a very ill child.

Objectives
Identify the challenges in pediatric assessment. Define a pediatric-specific assessment. sequence, including the Pediatric Assessment Triangle. Integrate knowledge of pediatric development to form a general impression and make the sick/not sick decision for children of different ages. Discuss the stay or go decision, with regard to treatment on scene versus transport.

The Challenge of Pediatric Assessment

Pediatric age range: 0 21 years Tremendous variation in physical, cognitive, and emotional development Distinguishing normal from abnormal requires age-specific knowledge.

What assessments can be made

From the door Before you touch the child Before you upset the child

Pediatric Assessment Triangle

Observational assessment Formalizes the general impression Identifies general category of physiologic abnormality Establishes the severity of illness or injury Determines the urgency of intervention

Pediatric Assessment Triangle

Appearance

Work of Breathing

Circulation to Skin

Steps in Pediatric Assessment

1. Prearrival Preparation 2. Scene Size-up 3. General Impression Assessment PAT 4. Initial Assessment ABCDEs and Transport Decision 5. Additional Assessment Focused History and Physical Exam, Detailed Physical Exam (Trauma) 6. Ongoing Assessment

Transport Decision: Stay or Go?

Indications for immediate on-scene treatment: Cardiac arrest Complete airway obstruction Decompensated shock Impending newborn delivery Seizures Wheezing Stridor Severe pain with normal blood pressure

Stay or Go?
Indications for immediate transport and treatment en route:
Incomplete airway obstruction Compensated shock Closed head injury with normal airway, breathing Multisystem trauma Inability to treat on-scene. Safety problems Equipment failure Procedure failure

Case Presentations
Look at the scenario Discuss what you need to be keeping in mind before you arrive?
What could be causing the problem? What do you need to be gathering prior to arrival?
Equipment Supplies

Scene size up Is the child safe with the caregivers? PAT ABC SAMPLE

Case Presentation
You respond to a call in the early morning Three-day-old infant who is unresponsive. Is this a problem? Why is the infant unresponsive? What equipment do you need to take with you to the patient?

Prearrival Preparation
Causes of unresponsiveness in a 3-day-old? Sepsis Congenital heart disease Inborn error of metabolism Seizure Abuse Equipment/medication Car seat available? Airway/IV Psychosocial issues

Scene Size-up
You arrive at a low-rise public housing complex. A very young mother and a fairly young grandmother meet you at the pavement with the baby in arms. The mother is crying. The grandmother is agitated. Whats wrong with him? I told them he shouldnt leave the hospital so soon! A large crowd of bystanders has gathered.

General Assessment: PAT

Appearance Tiny baby, little spontaneous movement; eyes open but no eye contact; highpitched cry Circulation to Skin Skin mottled, hands and feet blue Work of Breathing See-saw breathing; intercostal and subcostal retractions and nasal flaring

 Sick or not sick?

General Impression
The baby is sick. Physiologic abnormality: cardiopulmonary failure
High pitched cry Respirations abnormal Circulation abnormal

Begin management as you continue your assessment.

Initial Assessment: ABCDEs

A patent B RR 80; air entry decreased; SaO2 unattainable C HR 180; capillary refill 5 seconds; brachial pulse faint; femoral pulse palpable D baby stiff when taken from moms arms; arches, high-pitched whimper
E no rashes, bruises

Transport Decision
Stay or go? Are there problems with ABCs? BLS versus ALS?
Do you need an intercept?

Management Priorities
Stay and provide immediate management: Provide supplemental oxygen; consider bag-mask ventilation. Place on cardiorespiratory monitor. Make vascular attempt on scene. Transport and give crystalloid en route. Transport to pediatric receiving facility or critical care center based on local policy.

Additional Assessment: Focused History SAMPLE

Signs/symptoms: felt warm; did not awake to feed; difficult to arouse this morning. Allergies: none Medications: breastfeeding mom taking Demerol. Past medical problems:
Normal vaginal delivery at 37-weeks-gestation to 17year-old mom. Pregnancy complicated by hypertension. 20-hour rupture of membranes, no maternal or infant fever. Home at 24 hours

Last meal: breastfed 0300 Events leading to illness: ?

 What kind of problems did you find in the SAMPLE history?

Case Conclusion
En route: infant placed on oxygen and bag-mask ventilation begun. In the ED: infant resuscitated with fluids, cultures taken, and antibiotics given. Diagnosis: group B strep pneumonia and meningitis Outcome: hospitalized in pediatric ICU for 2 weeks.

Case Presentation
3-year-old with approximately 20-foot fall from construction scaffolding. Could this be a problem? What are critical elements of a fall? What equipment do you need to take with you to the patient?

Prearrival Preparation
What types of injuries is a 3-year-old likely to sustain with fall from height? Head intracranial bleed, skull fracture Chest pulmonary contusion; hemo-pneumothorax Abdomen liver and spleen injury Musculoskeletal extremity fractures Equipment/medications pediatric stabilization device; cervical collar; airway; IV Psychosocial

Scene Size-Up
You pull up to a suburban house under construction. A dad frantically leads you into the structure, where a small child is sobbing in her mothers arms. Dad gestures upward to indicate the platform from which the child fell onto a concrete pad.

General Assessment: PAT

Appearance Alert; makes eye contact; cries vigorously; sits up and yells, Go away!
Circulation to Skin Pink How do we categorize this childs physiologic status based on the PAT? Is she seriously injured? Work of Breathing No retractions, flaring, grunting

 Sick or not sick?

General Impression and Management Priorities

The child is stable and acting normally for a child her age, but the mechanism of injury is concerning, with potential for serious injury.

Initial Assessment: ABCDEs

A patent; actively resists cervical immobilization B RR 48; crying with good air entry; SaO2 not picking up C HR 160; CRT < 2 seconds; radial pulse strong; BP 110/80 D AVPU alert; kicks and thrashes E obvious deformity left forearm, skin intact; superficial abrasion left temple

Transport Decision
Stay or go? Spinal stabilization?
How?

ALS versus BLS?

Do you need an intercept?

Destination: Trauma center versus community hospital?

Management Priorities
Stay and provide immediate management. Provide supplemental oxygen. Place monitors. Stabilize spine. Go transport and attempt IV access en route. Assess weight and begin fluid resuscitation. Transport to pediatric receiving facility versus trauma center based on local policy.

SAMPLE History
Obtain SAMPLE history en route: Signs/symptoms: complaining of pain left arm. Allergies: none Medications: cold medication Past medical problems: ear infection and cold Last meal: burger and fries 45 minutes ago Events leading to illness/injury Family meeting with contractor at new home site. Child unobserved for 5 minutes. Parents witnessed fall. Cried immediately, no LOC.

 Was this child neglected or abused? Does the parents story make sense? Are the parents acting appropriately?

Detailed Physical Exam (Trauma)

Complete a detailed physical exam en route. Reassess frequently to monitor response to treatment.

Case Conclusion
En route: an IV started and 200 mL of normal saline was infused. In the ED: child became sleepy and required head and abdominal CT scan. Diagnosis: right parietal skull fracture, liver laceration, and elbow fracture. Outcome: admitted to pediatric ICU; home on day 5.

Case Presentation
You respond to a residence where a 3-year-old girl has been found unconscious. The parents tell you that the child was fine when put to bed at eight the night before. They awoke this morning to find toddler asleep on the living room floor, unable to arouse. You note partially filled cocktail glasses on the coffee table and an open bottle of gin on its side on the floor. The parents admit that they were too tired to clean up after a party last night.

General Assessment: PAT

Appearance Unresponsive, lying sprawled in a pool of vomit

Work of Breathing Normal

Circulation to Skin Normal

What is your general impression?

 Sick or not sick?

General Impression and Management Priorities

General impression: Sick Brain dysfunction; likely a metabolic/toxic cause Management priorities:
Immediate treatment: BLS: position, suction, supplemental O2. ALS: check blood glucose level.

Initial Assessment: ABCDEs

Airway open, vomit in mouth Breathing RR 16; symmetric chest rise; clear lungs; SaO2 94% Circulation HR 90; skin moist; capillary refill 2 seconds; BP 80/60 Disability AVPU = P; pupils sluggish but equal; decreased tone Exposure breath and clothes smell of alcohol; no signs of trauma

SAMPLE
Signs and symptoms unresponsive child Allergies -- none per mother Medications none per mother Past history normal healthy child Last meal supper at 6 pm night before snack at 8 pm Events parents awoke to find child in this condition

 Was this child neglected or abused? Does the parents story make sense? Are the parents acting appropriately?

Management Priorities
The patient is in impending respiratory failure because of alcohol ingestion. BLS: Consider airway adjunct. Prepare for bag-mask ventilation. Transport. ALS: Treat documented hypoglycemia. Establish IV access. Perform electronic monitoring. Consider ETI for airway protection if ALOC and absent gag reflex.

Case Progression
Blood glucose is 30 mg/%.
IV started on scene. D25W, 1 mL/kg IV administered.

Patient becomes somewhat more responsive, but she remains sleepy.

Key Concept: Hypoglycemia

Hypoglycemia is common complication of alcohol ingestion in young children. If the patient is awake, ask the caregiver to give oral glucose (soda or juice).
If patient is not alert or the gag reflex is depressed, give IV dextrose.

Key Concept: Risk Assessment

Determine: The substance ingested. Toxicity Dose ingested: mg toxin ingested per/kg body weight. Time since exposure. Call: Poison center or medical oversight to help with risk assessment.

Key Concept: Ingestions by Toddlers

Toddlers frequently ingest household products: solvents, cosmetics, plants, and cleaning liquids. Most ingestions in this age group involve single toxins. Few ingestions require charcoal or any specific treatment.

Case Progression
En route: patient remains stable, with progressive improvement in the level of consciousness.

ED Course
In the ED: repeat blood glucose 58. IV glucose infusion started, electrolytes, blood gas, and blood alcohol level sent. Social work consult obtained to evaluate home safety. Diagnosis: alcohol ingestion; hypoglycemia Outcome: social work call to childrens protective services (CPS) reveals an open case, with a past report of child neglect. Child is discharged the following day in the care of the maternal grandmother, pending CPS investigation.

Summary
Toddlers are highly susceptible to the metabolic effects of alcohol, particularly hypoglycemia. Accidental ingestions peak in the 2- to 3-year age group. Prevention of poisoning in the home requires constant vigilance by caregivers and multiple rounds of childproofing!

Case Presentation
You are called to a residence for a 10-year-old boy who is having trouble breathing. What could be the cause of a 10 year-old with trouble breathing? What equipment will you need to take to the patient on arrival?

Prearrival Preparation
Review the causes of respiratory distress in school-aged children.
Asthma Pneumonia Foreign body aspiration Anaphylaxis Chest trauma

Review team roles and possible management (airway equipment, medication doses, IV).

Scene Size-Up
You are first on scene to a home where you are waved into the living room by an anxious mother. The father is attending to a 10-year-old boy who is obviously working hard to breathe.

General Assessment: PAT

Work of Breathing Seated, leaning forward on outstretched arms; marked retractions and nasal flaring; audible wheeze

Appearance Anxious, alert, able to respond to questions with only single words

Circulation to skin Pale, lips slightly blue

What is your general impression?

 Sick or not sick?

General Impression
General impression:
Sick Respiratory distress

Physiologic problem:
Lower airway obstruction

Initial Assessment: ABCDEs

A patent, no stridor B RR 48; poor air entry; diffuse wheezing; SaO2 88% C HR 140; radial pulse full; capillary refill < 2 seconds; nail beds blue; BP 100/70 D AVPU alert E no signs of trauma or rash

Management Priorities
Immediate treatment:
Leave child in a position of comfort. BLS: Oxygen 15L by mask Nebulized albuterol 2.5 mg every 20 minutes for 2 doses. Repeat albuterol as necessary. ALS: Terbutaline SubQ .005 mg/kg Stay or Go? Give first albuterol treatment on scene and then continue en route.

Focused History: SAMPLE

Signs/symptoms: cold symptoms for 2 days, shortness of breath this morning Allergies: penicillin, seafood Medications: Flovent inhaler; Albuterol inhaler Past medical problems: asthma; anaphylaxis to seafood Last meal: breakfast 3 hours ago Events leading to illness/injury: wheezing started during PE class.

Key Concept: Asthma

Asthma is the most common chronic disease of childhood. Five million children have the disease. Death from asthma is rising and half of all pediatric deaths occur in the prehospital setting.

Key Concept: Factors that Suggest a More Severe Asthma Exacerbation

A severe or fatal asthma attack is more likely in a child with:
Prior intensive care unit admissions or intubation More than three ED visits in a year More than two hospital admissions in past year Use of more than one metered dose inhaler canister in the last month Use of bronchodilators more frequently than every 4 hours Progressive symptoms despite aggressive home therapy

Key Concept: Asthma Triggers

Common triggers of an asthma attack include:
Upper respiratory infection Exercise Exposure to cold air Emotional stress Passive exposure to smoke

Key Concept: Asthma Pathophysiology and Clinical Signs

Asthma is a disease of small airway inflammation.
It leads to bronchoconstriction, mucosal edema, and increased secretions.

Clinical signs and symptoms:

Tachypnea Tachycardia Retractions Wheezing or decreased breath sounds Pulse oximetry may be normal or low

Key Concept: Signs of Severe Asthma

Beware of the following features of the initial assessment, which suggest severe bronchospasm and respiratory failure:
Altered appearance Exhaustion Inability to recline Interrupted speech Severe retractions Decreased air movement

Management Priorities
Alert respiratory distress
Position of comfort Supplemental oxygen Inhaled albuterol

Not alert respiratory failure

Bag-mask ventilation Subcutaneous terbutaline ETI if apneic

Case Progression
En route: patient received two 2.5 mg nebulized albuterol treatments. ED Course: the patient received continuous nebulized albuterol and IV corticosteroids and was admitted to the Pediatric Intensive Care Unit. Diagnosis: acute asthma exacerbation

Summary
Asthma is the most common chronic disease of childhood. The severity of symptoms varies widely between individuals. Treat aggressively in children with a past history of severe attacks or signs of respiratory fatigue on exam. Inhaled beta-agonists and oxygen are the cornerstones of both field and hospital treatment.

Review
Answer the following questions as a group. If doing this CE individually, please e-mail your answers to: shelley.peelman@provena.org Use July 2011 CE in subject box. You will receive an e-mail confirmation. Print this confirmation for your records, and document the CE in your PREMSS CE record book.

Follow Up Quiz
1. What are the assessments made using the PAT Triangle?
1. 2. 3.

 2 Why is the PAT such a valuable tool when approaching children?

A. It involves touching children early in the assessment. B. It involves observing the child from a distance before touching and agitating them. C. The assessment must be done within 6 inches of the child. D. It is useful for children under age 2 only.

 3. Another value of the PAT triangle is that it allows the provider to:
A. estimate the childs age B. estimate vital signs C. determine which protocol to use D. determine if the child is sick or not sick

 Low blood sugar in children:

A. B. C. D. May be seen with ingestion of alcohol Is rare Need not be measured Is common in asthma attacks

 Which of these signs and symptoms does not suggest respiratory failure in a child?
A. Unable to speak in sentences without taking a breath between words B. Extreme fatigue C. able to lay flat D. Retractions

Answers
1. PAT =
Appearance Work of Breathing Circulation to skin

2. 3. 4. 5.

B D A C