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!

Work of Breathing
No retractions,
flaring, grunting

Circulation to Skin
Pink
How do we categorize this childs physiologic status
based on the PAT?
Is she seriously injured?

 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

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

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

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