Emergency Medical Services Seattle/King County Public Health 401 5th Avenue, Suite 1200 Seattle, WA 98104 206.296.4863 Last Updated December 14, 2015
Pediatric Patient Overview Contents PEDIATRIC BASICS... 3 Definitions... 3 Developmental Changes... 3 Vital Signs... 4 PEDIATRIC ANATOMY AND PHYSIOLOGY... 5 Respiratory System... 5 Circulatory System... 5 Nervous System... 6 Gastrointestinal System... 6 Musculoskeletal System... 6 Other Considerations... 6 2015 Seattle/King County Emergency Medical Services 2
PEDIATRIC BASICS Pediatric patients present special challenges to the EMT. Children are more than small adults and the techniques and equipment used for adults cannot be simply scaled down for children. Evaluation and treatment of pediatric patients is often different than for adults; yet we see comparatively few badly injured or critically ill pediatric patients. Obviously this is fortunate, but it means that we lack the familiarity and experience with these techniques. Lastly, caring for a very sick or injured child has an emotional component for the rescuer that cannot be overlooked. All of these issues add to the anxiety often felt by EMTs when treating pediatric patients. Fortunately this anxiety can be addressed by having a clear understanding of the unique nature of pediatric patients, their illnesses and injuries, and the best ways to assess and treat these patients. Pediatric patients are NOT just little adults! Definitions In general, a pediatric patient is anyone under the age of 18. However, the younger the child, the more differently they present than an adult and the more aware you need to be of their unique presentation and needs. This is commonly accepted terminology when describing pediatric patients. PEDIATRIC DEFINTIONS Newborn/Neonate Infant First month of life First year of life Toddler Age 1 to 3 Preschooler Age 3 to 6 School-aged Age 6 to 12 Adolescent Age 12 and up Obviously patient characteristics are on a continuum from infancy to adulthood, but it sometimes helps to break this continuum into discrete categories of growth, behavior, and development. Developmental Changes Knowing normal behavior can help you determine if the child is injured or ill. Obviously it is normal for an infant to be unable to tell you where she hurts, but you would be surprised if an 8 year old did not answer your questions. Keep in mind, however, that children progress through development at different rates. Some children are developmentally delayed and may never reach certain milestones. The families and caregivers of such children will be invaluable in helping you understand the child s baseline and how they differ from that baseline. 2015 Seattle/King County Emergency Medical Services 3
CATEGORY AGE CHARACTERISTICS Infant 0-2 months 2 to 6 months 6 to 12 months Sleep, eat, cry. Can focus on faces. Does not show a preference for caregiver/parent over a stranger. Spend more time awake, recognize caregivers, can roll over Make babbling noises progressing to simple words. Crawling, walking, teething. Usually unafraid of strangers Toddler 1 to 3 years Walks, runs, and begins to explore the world, generally unafraid. Can speak some words and follow simple instructions. During the terrible 2s children may be afraid of strangers and reluctant to be examined or restrained. Preschool age child 3 to 6 years Rapid increase in language, more coordinated physically, toilet training usually accomplished School age 6 to 12 years As children progress through this stage, increasingly complex thought patterns, respond coherently to questions and requests, concerned about social context and their bodies Teenagers 12 to 18 years Increasingly adult decision making and thought patterns. Beginning of puberty, concern about body image. Risk taking, peer pressure. Vital Signs Vital signs also change as a child matures. In general, as a child gets older, the blood pressure increases and the heart rate and respiratory rate decrease. There is a formula that can help you calculate the normal blood pressure for a child s age. Pediatric systolic blood pressure: 90 + (2 X age in years) For example: a 4-year-old would be expected to have a systolic blood pressure of 90 + (2 X 4) = 98. Respiratory rates will vary but a respiratory rate over 60 is abnormal at any age. You can also carry a chart that lists expected vital signs for each age. Be aware that children with medical complexity may normally have vital signs that are outside the listed range. For example, a child with a congenital cardiac problem may have a higher than normal respiratory 2015 Seattle/King County Emergency Medical Services 4
rate and heart rate. Family or caregivers will often know the child s usual vitals signs, giving you a baseline for comparison. CATEGORY BLOOD PRESSURE HEART RATE RESPIRATORY RATE Newborn 50 to 70 100 to 200 30 to 60 Infant 1 month to 1 year 70 to 95 100 to 160 25 to 50 Toddler 80 to 100 90 to 150 20 to 30 Preschooler 80 to 100 80 to 140 20 to 25 School-age 80 to 110 70 to 120 15 to 20 Teenager 90 to 110 60 to 100 12 to 20 PEDIATRIC ANATOMY AND PHYSIOLOGY Infants and children are not miniature adults, but have anatomic and physiologic features that are unique and can present special challenges to the EMT. When assessing a critical pediatric patient ask yourself whether it is a cardiac issue, a respiratory issue, or both. Respiratory System Compared to an adult, a pediatric patient has an airway that is narrower in diameter, shorter in length, and more flexible. In addition, children have proportionally larger tongues, larger epiglottises, and larger heads that can impede the ability of the EMT to keep the airway open. Children s lungs are proportionally smaller; at the same time, their higher metabolic rate means that their oxygen demand is higher. Furthermore infants and young children can experience respiratory muscle fatigue leading to respiratory failure. The most common cause of cardiac arrest in pediatric patients is respiratory insufficiency or respiratory arrest. All of these differences are most pronounced in infants and young children, and become less important as a teenager reaches adulthood. At any age, proper management of the pediatric airway is one of the most critical tasks of the EMT. Circulatory System Pediatric patients have a much more resilient circulatory system than adults. This can be a problem when trying to assess a pediatric patient for the presence of shock. Pediatric patients can increase their heart rates dramatically in an attempt to maintain blood pressure in the 2015 Seattle/King County Emergency Medical Services 5
face of fluid loss. They can also vasoconstrict their peripheral blood vessels to redistribute blood to their core. The result of these physiologic responses to fluid loss is that a pediatric patient may be in shock and still show a normal blood pressure. The EMT must be careful to NOT rely on blood pressure but instead look for other signs such as cool, pale skin and increased heart rate. Children can rapidly progress into profound shock. Nervous System Pediatric patients have proportionally larger, heavier heads than adults. This leads them to suffer a higher incidence of head injuries from falls and accidents. Additionally, the developing brain is more fragile and prone to bleeding and swelling. Head injuries in pediatric patients can range from shaken baby syndrome in infants, to concussions in older children who are injured playing sports. Shaken baby syndrome is a form of child abuse that occurs when a baby is shaken violently by a parent or caregiver. The brain bounces from one side of the skull to the other, causing bleeding, swelling, and tearing of brain tissue. Gastrointestinal System Internal organs in the abdominal cavity of a pediatric patient are proportionally larger and less well protected by the abdominal muscles. Liver, spleen, and kidneys are prone to injury even after an apparently minor accident. Look closely at mechanism of injury, such as the presence of a lap belt that might have put pressure on the child s abdomen. You may be able to see bruises from the seat belt that also indicate abdominal trauma. Musculoskeletal System Children have soft, pliable bones, which provides some protection from fractures. However the lack of fractures even after significant trauma can mask a serious injury. Consider an unrestrained child who has been thrown against a car dashboard in an accident. That child may have no obvious rib fractures. However the flexibility of the ribs means that the chest wall may have been significantly deformed, injuring the underlying structures. When evaluating a pediatric trauma patient, keep in mind that even if there are no fractures, the underlying soft tissues may still be damaged. Other Considerations Infants and children have a large surface area compared to their body mass. This means that they can lose heat more quickly than an adult, becoming hypothermic. Additionally, neonates and younger infants cannot shiver. While cold is usually a greater problem, in hot conditions, infants especially may be unable to dissipate excess heat and can develop heat-related problems. 2015 Seattle/King County Emergency Medical Services 6