By Kevin Grange
Sick or injured pediatric patients are notorious for showing vague changes in their mental status and vital signs, only to suddenly deteriorate and become critical.
“With kids, you need to start at death and work backwards,” my paramedic school teacher taught. “If you’re not two steps ahead, you’re eight steps behind.”
When you’re called to help a pediatric patient whose life hangs in a critical balance between compensated and decompensated, here are seven ways to help save a pediatric patient.
1. Acknowledge anatomical differences
You should avoid thinking of pediatric patients as little adults and instead understand their anatomical differences. For example, a child’s head is larger in proportion to their body than an adult, which makes them more susceptible to trauma, especially after a fall. Children also have less blood and are, therefore, in greater danger of developing shock or bleeding to death from a wound.
Children have larger tongues and smaller airways with more soft tissue, making them more susceptible to foreign body and airway obstructions. The temperature control mechanism on pediatric patients is also unstable and they dehydrate more easily. The first sign of shock is often a rapid heart rate and irritability, a drop in blood pressure is a late, ominous sign, and cardiac arrest is usually secondary to respiratory failure causing respiratory arrest.
2. Use the pediatric assessment triangle
You should be able to form your general impression of the child from the door and determine if the child is sick or not sick. Before you approach the patient, take a moment to look at their ABCs — appearance, breathing and circulation — from across the room.
- Is the child alert, agitated, sleepy or unresponsive in regards to their appearance?
- Is their airway open?
- How is their work of breathing?
- Do you hear any sounds from them breathing?
- What is their respiratory rate?
- Do you see an accessory muscle use?
- What is the skin color and condition?
This set of visual vital signs should give immediate clues about the need for rapid treatment and transport to the hospital.
3. Attack the chief complaint
Since pediatric patients often can’t vocalize their chief complaint — or give a detailed history of their present illness or injury — don’t fall into the trap of walking into the room and delaying your primary assessment to get the full story from mom or dad. If you obtain OPQRST and SAMPLE histories first, precious time can pass before you even begin to assess the patient.
Instead, walk into the room, quickly determine the chief complaint and attack it by immediately assessing the child’s airway, breathing, circulation and treating any life threats. Once the child is stable, move on to the secondary assessment to find out what happened, the child’s medical history and vital signs.
4. Pay attention to the parents
Many parents seem to have an intuitive sense of their child’s health. When a mom or dad says a vague phrase like, “My baby just isn’t acting right,” or “Something’s very wrong with my child,” your index of suspicion should rise and it’s time to immediately find out exactly what the parent is noticing.
Conversely, I’ve also run numerous calls for a pediatric patient who “overdosed” or who is “altered,” only to find the child is perfectly fine and the mother or father is drunk or on drugs. In these sad cases, the parents were so altered they thought their babies had stopped breathing or swallowed the pills, so we immediately called the police and child protective services to look out for the kids.
When you run a pediatric call, always keep your eyes open for neglect or abuse, such as bruises in multiple stages of healing or burns that present in the pattern of a splash or cigarette. It is up to you to be the child’s advocate. We don’t assume it is child abuse, but we assume it could be.
5. Make your job easier
Like many emergency departments — or pilots preparing for a departure or dealing with an in-flight emergency — I am a big fan of using checklists and reference charts to deal with an emergency.
The vital signs for pediatric patients change from 0-6 months, 6-12 months, 1-3 years, 3-5 years, 6-10 years and from 11-14 years. Trying to remember all the correct numbers for an age-appropriate heart rate, respiratory rate and blood pressure on a stressful call is simply too much.
Instead, keep a pediatric vital sign reference card in your pocket, clipboard or smartphone, and use the Broselow Pediatric Emergency Tape which lists correct vital signs, drug dosages and equipment sizes.
When you use these resources on-scene, you are less likely to make critical errors and you present to the parents as an EMT or paramedic that is diligent, professional and methodical.
6. Know childhood development by age
On a pediatric emergency, we can’t always get a good history from the patient or parent but, by knowing the characteristics and behaviors of childhood development by age, you can figure out what constitutes an altered patient, what the chief complaint might be and how to best handle it.
- Infants (0-12 months) generally respond to the voice or face of their parents, like to be held by caregivers and crying can indicate pain, discomfort or hunger.
- Toddlers (1-3 years) are curious and, therefore, more apt to have an ingestion emergency or foreign body airway obstruction. Toddlers fear separation from their parents, so giving them a stuffed animal and allowing them to sit on their parents’ lap might help build trust.
- Preschoolers (3-5 years) can talk with simple words, but often can’t understand what’s happening and are scared by the sight of blood, so it’s important to bandage even the simplest cuts and give constant reassurance.
- School-aged kids (6-12 years) can generally answer questions and follow the guidance of EMS providers but have very vivid imaginations, especially about death, and might need constant reminders that they’ll be okay.
- Adolescents (13-18 years) can provide accurate information but fear permanent scarring with trauma, feel modesty is important to them, and can get caught up in the hysteria of a 911 call, so it’s important to be well-versed in a variety of calming measures.
7. Competence breeds confidence
Most EMS providers don’t run many pediatric emergency calls so it’s imperative to keep your skills and knowledge base up by running scenarios with your agency, reading articles and taking classes such as Pediatric Advanced Life Support and Emergency Pediatric Care.
Then, when you respond to a pediatric emergency, you’ll find yourself better prepared to deal with an emergency. Competence breeds confidence and confidence breeds competence.
Share your pediatric assessment tips by email to editor@ems1.com. What works for you? What are the resources, courses and techniques you recommend?
ABOUT THE AUTHOR
Kevin Grange works as a paramedic with Jackson Hole Fire/EMS and is the author of two memoirs. “Lights and Sirens: The Education of a Paramedic” is about paramedic school and the second, “Wild Rescues: A Paramedic’s Extreme Adventures in Yosemite, Yellowstone, and Grand Teton,” is about working as a paramedic in three of America’s National Parks.
This article was originally posted on Mar. 7, 2016, and has been updated.