Pediatric Assessment

Objectives
At the conclusion of this chapter you should be able to:

1. Discuss the age differences affecting the assessment of pediatrics

2. Discuss the pediatric assessment triangle
3. Discuss the CUPS assessment for establishing priorities
4. List the elements of the pediatric focused and physical exam
5. Discuss the importance of proper prehospital documentation of patient assessment

Case Study
You are 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 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 established an IV line using a butterfly needle in the child's scalp. The
doctor says that he had great difficulty 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 immediately begin your initial
assessment taking note that the child has an altered mental status. The
child's breathing is regular but the pulse is weak and rapid (you can barely
feel the child's radial and pedal pulses). The child otherwise appears to be
well perfused. You decide to transport immediately.

En route to hospital you put the child on supplemental oxygen. The child's
pulse oximetry is 95% and air entry to the lungs is equal and clear
bilaterally. The child's capillary refill is 3 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 the child's mental status and the child seems to be a little more aware of it's surroundings. Using the CUPS
assessment you decide that the child is unstable due to the altered 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. Nothing is out of the ordinary except
for the fact that the 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 stopped 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 assessment
findings.

This case study highlights the fact that you are not always able to determine exactly what is wrong with a patient. You
must simply go through the numbers and intervene as necessary as you proceed through your assessment, and provide
rapid transport to the nearest most appropriate medical facility.

Introduction
Children are not simply small adults; the physiological, emotional and psychological differences as compared to adults
are profound. When faced with an injured or ill child, you may find yourself experiencing a great deal of fear,
uncertainty, 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; failure to do so will make assessment of the child difficult if not
impossible and may even worsen the child's 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 members 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 – children are more likely to panic at even the slightest injury let alone major trauma
or illness. The child may be inconsolable which increases the anxiety of both rescuers and family members alike.
Response of family members – parents, child minders and family members may be beside themselves with an
array of various emotions as a result of the child’s injury/illness.

General Considerations When Dealing with Pediatrics

1. Remain calm
2. Stay at eye level with the child
3. Make yourself known to the child in friendly and simple terms.
4. Be cheerful and smile.
5. Be patient with the child
6. Be gentle when examining the child

Age Differences Affecting the Assessment of Pediatrics

The assessment and treatment of children as well as 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 Responds well to cooing sounds.
Doesn’t mind clothing being removed or being examined.
Doesn’t mind strangers touching him.
Should not be separated from parents.

6 months to 24
months May respond to cooing sounds, may prefer to a soft toy or flashing light.
Doesn’t mind clothing being removed or being examined provided you do so
in a calm, reassuring and professional manner.
Perform toe-to-head survey.

2 years to 3
years 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 explain
to him things to come e.g. emergency room procedures etc.
Do not try to remove the child from the child's parents.
Obtain and maintain the child’s confidence or the examination will get very
difficult.
Perform toe-to-head survey.

3 years to 5
years 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.

5 years to 12
years May still be disturbed by the presence of strangers or removal from parents.
Are modest and do not like having their sexual parts exposed.
Have a good ability to communicate which can help to allay any concerns.
Likes to know what is happening and wants to be “treated like and 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 deal of reassurance, 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 remains the same as for adults with a few exceptions. If you know that the incident involves pediatrics,
you should mentally prepare yourself for the challenge ahead.

As you approach the patient, you should try to get an overall assessment of the patient. Some questions that you
should ask yourself are:

1. Is the child moving/conscious?

2. Is the child lying in a peculiar position?
3. Are there any obvious mechanisms of injury?
4. Is there any sign of massive bleeding?
5. 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 interventions are required, or if
you should take a more relaxed approach to gain the child's trust. It must be pointed at that the initial assessment
must be stopped as soon as a critical condition has been identified and the appropriate interventions should be made.

Always take a moment to assess the child from a distance if possible.

The Pediatric Assessment Triangle

An accepted standard of pre-hospital pediatric care is the Pediatric Assessment Triangle. All three of the components
are 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 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 of excessive bleeding?

Initial Assessment
Using the information gathered from your First Impression, a complete Initial Assessment must be undertaken. This
assessment must be done in far greater detail than the first impression. The purpose of the initial assessment is to
identify life-threatening conditions and treat them 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 moving around and interacting with its environment during the First Impression you can most often
move straight to the next step (Airway). If the child was not moving or appeared unresponsive gently shake the child to
determine the level of responsiveness.

Communicating with a child to obtain a history can prove very difficult if the parents or guardians are not present or
incapacitated. Obtaining a history is basically impossible with a neonate or infant whose communication abilities are not
yet developed (there is nothing more disconcerting than a child screaming blue murder while you, a complete stranger,
are prodding and poking).

AVPU
During the First Impression you would have determined whether the child was alert or not. During the 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 adults with the only exception that the severity of the child's condition between the
different levels is far greater than with adults. Anything other than "Alert" should be considered a grave sign in a
pediatric patient.

A The child is alert, opening its eyes looking around, crying, moving its limbs spontaneously.
V The child responds only to Voice.
P The child responds only to painful stimulus.
U The child is unresponsive.

Interventions For Children with a Decreased Level of Consciousness

Children with a decreased level of consciousness are at great risk for airway compromise or respiratory difficulties. Both
airway and respirations should be closely monitored. The minimum level of treatment is the administration of
supplemental oxygen. Additional airway support and assisted ventilations may also 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 susceptible to damage or infection. A child's airway should never be extended to past the "sniff the morning
breeze" position as this will cause the child's airway to "kink" and become obstructed.

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 can easily cause airway obstruction by flopping backward in
the throat should the child be in a supine position.

A child's mouth should be visually 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, or not
maintainable without intubation or foreign body removal.

If a child has an altered level of consciousness as detected during either the first impression or AVPU score, an
immediate assessment of the airway must be performed. During the assessment you must make a classification of the
child's airway as mentioned in the previous paragraph: patent and maintainable or not maintainable without
intubation/foreign body removal.

The following steps should be performed during this part of the initial assessment:

1. Listen for air movement and look for any chest or abdominal movement
2. Feel for air movement from the child's mouth
3. Be aware and take note of any abnormal noises such as gurgling, snoring and stridor.

Airway Interventions
If the child has no sign (or very little signs of) air movement, attempts to open the airway must be made immediately.
An obstructed airway can be the result of either poor airway positioning or an obstruction.

If the child is unconscious or unable to maintain 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 such as naso- or oro-pharyngeal tubes. Endotracheal intubation may be required in some cases.

If the child has a complete airway obstruction:

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 assisted ventilations with a bag-valve
mask with supplemental high-concentration 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 airway obstruction (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 sounds, visible blood, secretions or vomitus the airway must be suctioned or aspiration
may occur.

Breathing
Breathing assessment follows on directly from the airway assessment described above. The assessment of breathing
includes:

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 An evaluation of the efficiency of the child's respirations i.e. rate, rhythm, depth and effort
Auscultation of breath sounds
Assessment 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 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-seconds would work
out to 70 respirations per minute (35 x 2 = 70).

Normal values for a child's respiration rates are:

1 month to 1 6 to 10 10 to 18
2 to 6 years
Neonates year years years
(from 22 to
(up to 7lbs) (from 7 to (from 44 to (from 75 to
44lbs)
22lbs) 75lbs) 110lbs)
Respiration
30-70 20-40 20-30 20-25 15-20
Rate

If the child's respirations are outside of the above ranges it means that the child is not receiving sufficient
oxygen or discharging sufficient carbon dioxide.

2. Assess the depth of the child's respirations

This is an indication of the volume of air being moved 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 child for signs of increased respiratory effort

Signs of increased respiratory effort include:

Retractions on inhalation - where the skin appears to pull in into the sternal notch, above the
clavicles, between the ribs (intracostal retractions) or below the ribs (subcostal retractions)
Nasal flaring - a widening of the nostrils in infants and toddlers to allow more air 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 lines (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 sounds to be transmitted from one side of the
chest to the other.

Listen for abnormal breath sounds. Abnormal breath sounds include:

Grunting - a whining or "uh" sound on expiration.

Wheezing - either a high- or low-pitched sound heard on expiration. Expiratory wheezing is 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 spasm. Rhonchi is
rumbling sound that is clearer on expiration and coughing.
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 alveoli.
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 clearer
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.

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 "A silent grave awaits a silent chest" - Nancy L. Caroline
5. Assess the color of the child's lips, tongue and buccal mucosa - Normally these are pink in color. Pale or blue color
is a sign of hypoxemia which is caused by respiratory failure. Poor oxygenation may also cause decreased
circulation which will cause the skin to be pale.

6. Assess the chest for life-threatening injuries - Check for chest injuries that will compromise the child's respirations
and require immediate medical intervention e.g. tension pneumothorax, open pneumothorax (sucking chest
wound), flail chest or impaled 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. obstructed airway, respiratory failure/arrest or
decreased level of consciousness.

The pulse oximeter provides a continual measurement of arterial oxygen saturation (SpO2) and the pulse
rate based on an initial baseline reading. Arterial oxygen saturation is an indication of the efficiency of the
lungs in oxygenating the blood. The following table shows the various ranges of SpO2:

Various Ranges of SpO2

SpO2 Condition of child

From 95 to 100% Normal

From 91 up to 95% Mild hypoxia

Less than 91% Severe hypoxia

The pulse oximeter reading changes frequently and is to be used as adjunct only. A pulse oximeter can
never be used to determine if oxygen should be withheld - TREAT YOUR PATIENT, not your equipment.

Breathing Assessment Interventions

If there is any indication of respiratory compromise the following steps should be followed:

Administer high-flow oxygen at high concentrations for any sign of respiratory compromise such as:
Variations in rate, depth or effort of breathing
Abnormal breath sounds
Cyanosis

For infants in respiratory distress deliver as close to 100% oxygen as possible.

Assist ventilations with a bag-valve-mask and supplemental high-concentration oxygen in all cases where there is
inadequate ventilation or respiratory failure/arrest.

If present, treat bronchoconstriction with supplemental oxygen and the appropriate medications.

Seal any sucking chest wounds with a one-way valve type dressing (to allow air to escape the chest but not to
enter it).

If the child shows the signs of tension pneumothorax (distended neck veins, tracheal deviation, anxiety, cyanosis,
decreased lung compliance etc) the pressure inside the chest must be released by means of a needle
thoracocentesis.

Cardiac arrest in children is generally secondary to respiratory failure and should always be closely monitored. 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. Such clinical signs that should be considered are (in no particular order of priority):

1. Level of consciousness
2. The child's agitation levels
3. Cyanosis
4. Cardiac status (BP, rate, rhythm and strength of pulse etc.)
5. Mechanism of injury
6. Chest auscultation (air entry should be equal bilaterally and clear)

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 7. Child's history (asthma, wheezing etc)
8. Pulse oximetry (as an adjunct only)

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 bleeding is present it must be controlled with direct pressure.

2. Check for central 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 good 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. 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. Compare the two pulses, the rate, rhythm and strength should be the same (although the peripheral
pulse will feel a little weaker than the central pulse). If you cannot locate the peripheral pulse or if it is significantly
weaker or irregular, inadequate peripheral perfusion is present which is indicative of shock.

4. Calculate the pulse rate. Count the pulse rate for 30 seconds and multiply that by two to determine 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)
Pulse Rate 120-150 115-130 80-115 85-100 70-80

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, 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 over the apex of the heart.

The formula for estimating the pediatric upper limit heart rate is: Rate = 150 - (5 x age in years) 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:

Color Condition of Child

Pink Normal

Pale Abnormal / Poor perfusion

Bluish Abnormal / Hypoxia

Mottled Abnormal / Shock

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 from pale to the color of the surrounding area within 2 seconds. Press the area that
is the warmest to ensure the best possible perfusion to the area being checked.

8. Only once the circulatory assessment has been completed should the blood pressure be taken. For children aged
3-years or younger the presence of a strong central pulse indicates adequate blood pressure and the presence of a
strong peripheral pulse indicates a good blood pressure. In children over 3-years of age the blood pressure should
only be measured if time allows as the process may be time-consuming.

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 DO NOT delay transport to get a blood pressure reading.

Blood pressure should only be measured 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 respiration and pulse rates. Select an appropriately sized blood pressure cuff (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 the various age groups.

Blood Pressures for the Various Age Groups

1 month to 6 to 10 10 to 18
2 to 6 years
Neonates 1 year years years
(from 22 to
(up to 7lbs) (from 7 to (from 44 to (from 75 to
44lbs)
22lbs) 75lbs) 110lbs)
Average Blood
74/40 85/60 90/60 95/62 105/65
Pressure

To estimate the lower limit of a child's systolic blood pressure use the following formula: BP = (2 x age in
years) + 70 e.g. a child that is 10-years old will have an estimated lower limit 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 consciousness

Abnormal airway assessment
Abnormal breathing assessment
Bradycardia
Tachycardia
Any sign of decreased perfusion

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 changes in the child's condition. Dysrhythmias in children should only
be treated if they compromise the child's breathing or circulation, or if the dysrhythmia is likely to degrade
into a lethal rhythm e.g. ventricular tachycardia.

If a child's pulse is absent, rapidly determine the rhythm to see if either pulseless ventricular 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 difficult to locate a child
or infant pulse (even at the best of times). A child requiring cardiac compressions will show clear signs of inadequate
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 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 (pause during the ventilations)
until the child is 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, they do so quickly and the child's condition can rapidly
deteriorate. Signs of shock must be treated aggressively as they occur and the underlying cause of shock should be
treated if possible. Treatment for shock includes:

Administration of high-concentration oxygen (this should be done during the airway/breathing assessment)
Control any massive external bleeding. Children have far less blood than adults and even the smallest amounts
of blood loss can have serious consequences.
Unless contraindicated by possible injury, elevate the child's legs to above the level of the heart.
Obtain IV access and administer a bolus of either saline or Ringer's lactate at 20mL/kg IV 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 of body heat by wrapping the child in a space blanket. Small children are more susceptible to
loss of body heat than adults.

Interventions for Dysrhythmias

Bradydysrhythmias

The most common cause of bradycardia in children is hypoxia. First reassess the child's airway and
breathing to ensure that oxygenation and 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 dysrhythmia is a wide or a narrow complex.

Wide complex tachydysrhythmia

If the patient shows signs of cardio-respiratory insufficiency, cardioversion or pharmocologic

treatment may be required.

Narrow complex tachydysrhythmia

Determine if the rhythm is a sinus tachycardia which will most likely be cause by easily
correctable mild hypoxia or hypovolemia. If the dysrhythmia is NOT a sinus tachycardia the
child's perfusion should be carefully reevaluated. If there are signs of cardio-respiratory
insufficiency then either immediate cardioversion or cardioversion with pharmacologic agents
should be performed.

CUPS Assessment
After the initial assessment is complete, do a CUPS assessment:

P - Potentially
C - Critical U - Unstable S - Stable
Unstable

Breathing is absent or Airway, breathing or Child does not appear Child appears normal.
child is having great circulation are to be in respiratory
difficulty in breathing. compromised. distress given your
Increased difficulty in general impression but
breathing. is susceptible to
respiratory distress
based on prior history.

Bradypnea or Tachypnea. Normal to slightly Normal respirations.

tachypnea with elevated respirations.
intermittent periods of
apnea.

Child is cyanosed or Child may appear pale. Child is pink. Child is pink.
pale.

Pulse oximetry is less Pulse oximetry greater Pulse oximetry greater Pulse oximetry greater
than 90% than 90% but less than than 95% than 95%
95%.

The CUPS assessment will help you determine whether to do further assessment on scene or initiate urgent transport to
the nearest medical facility.

If the child is critical or unstable, 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 that are based upon the child being anything other than "Normal" even though the child does
not appear to be in distress. A dangerous mechanism of injury can class a child as potentially unstable even if 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.

Reassessment
As mentioned earlier, a child's condition can deteriorate rapidly. Assessment should be ongoing until arrival at an
appropriate medical facility and hand over to the emergency room staff. Continuously monitor all elements of the initial
assessment as well the vital signs and CUPS assessment.

Vital Signs
Vital signs are age specific, although it is extremely difficult if not impossible to accurately remember the vitals signs for
the different age groups, it must be kept in mind that a 10 year old with the vital signs of a 10 month old would be in a
serious 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, Pulse and BP

Age Weight (Lbs) Average BP Pulse Respirations

up to 7
Neonates 74/40 120-150 30-70

from 7 to 22
1 month to 1 year 85/60 115-130 20-40

from 26 to 44
2 to 6 years 90/60 80-115 20-30

from 44 to 75
6 to 10 years 95/62 85-100 20-25

from 75 to 110
10 to 18 years 105/65 70-80 15-20

The above are merely a guideline. Always be sure to get the “big picture” and assess the condition of a child as a whole.
It is also important to take the child’s size into account, some 4 year olds are the size of 8 year olds.

Pediatric Glasgow Coma Score

The Pediatric Glasgow Coma Score is a modified version of the Adult Glasgow Coma Score and takes into account the
limited vocabulary and communication skills of pediatric patients. A copy of the Pediatric Glasgow Coma Score should
be kept in the rescuers equipment bag as remembering it while under stress will be unlikely.

Children over the age of 5 years can generally be assessed using the adult Glasgow Coma Score.

Eyes Verbal Motor

Normal movement of limbs
Smiling, cooing and
(reaching out with hands
appropriate crying for infants
Eyes open spontaneously 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
Normal crying for infants to
Eyes open to voice (or
3 confused/disoriented speech 4 Localization of pain 5
shout)
for children over 5 yrs

Consolable crying for infants Normal flexion for infants

Eyes open to painful
2 to inappropriate words for 3 to withdrawal by flexion for 4
stimulus
children over 5 yrs children over 1 yr

Grunting for infants to

Abnormal Flexion
Eyes do not open 1 incomprehensible noises for 2 3
(decorticate rigidity)
children over 5 yrs

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 Grunting for infants to
Abnormal Extension
incomprehensible noises for 2 2
(decerebrate rigidity)
children over 5 yrs

No Verbal response 1 No motor response 1

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 improve, another may decline e.g. an initial assessment of the child's GCS reveals Eyes - 3, Verbal 4
and Motor 4 (totaling 11/15), a few minutes later the child's GCS is Eyes -2, Verbal -3 , Motor - 6 (totaling 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 initial interventions and early transport are a priority. 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 sufficient personnel on scene, one team member 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 transport to hospital.

If the child is non-urgent a more detailed history of the child's condition can be collected. Typically the history is
obtained from the parents but should the child be old enough they should be given the opportunity to answer questions
for themselves.

SAMPLE History

S SIGNS & SYMPTOMS

In pediatric cases it will probably be easier to note signs as opposed to asking the child
what is wrong. The signs & symptoms part of the SAMPLE history will include all the
findings in the preceding assessments.

A ALLERGIES

This information can be obtained from medic alert bracelets or family members. Special
note must be taken of any allergies to any medications.

M MEDICATIONS

Medicine (prescription or otherwise) that the child has taken that day, or takes regularly.
Again, this information would have to be obtained from a family member, alternatively
the information can be obtained from medicine bottles (do not waste time trying to
determine what the child took).

P PAST MEDICAL HISTORY

A small child is unlikely to know a detailed medical history. Try to establish whether the
child has had previous hospitalizations, operations, complications and any serious
underlying illnesses.

L LAST MEAL

At what time did the child last eat, what did the child eat (is it something the child
normally eats), was it a regularly scheduled meal, has the child being eating normally?

E 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 has been completed, you should determine if any of the additional findings will alter the CUPS
assessment and act accordingly.

Additional history
You 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 consciousness?
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 or upper airway 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 external 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.
Inquire as to whether the child has been vomiting or has had diarrhea, and for how long.
Also make inquiries into what the child's fluid intake has been like for the past few days.
If possible try and determine how often the child has urinated.

5. Trauma

Determine if the child has suffered any major trauma in the recent past e.g. unrestrained motor
vehicle collision, fall from significant 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 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 recently, what that temperature was and
how the temperature was taken i.e. oral, rectal or tympanic.
Did the child have any neurological changes during the fever.
Find out what anti-pyretic medications were given to reduce the fever.
Has the child suffered any 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.
Ask if the child has had any seizures, cramps, nausea, vomiting or changes in behavior
Discretely try and determine whether this was a suicide attempt

9. Burns

Determine the source of the burn e.g. fire, steam, electricity, chemicals
Determine the location and extent 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.

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 more than four weeks premature?
Has the water broken?
Was the fluid discolored e.g. brown, green or bloody?
Has the mother recently abused any substances e.g. narcotics, alcohol
Has the mother gone for regular check-ups?
Are there any problems that have been 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 should be reevaluated.

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 interventions to perform a physical
exam. If it does interfere with the ongoing assessment of the child's ABC's the physical exam 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 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 you to complete the entire assessment.

During the assessment be alert for any DCAP-BTLS (deformities, contusion,

abrasions, punctures, burns, tenderness, lacerations or swelling). DCAP-BTLS
Examine what is most painful LAST and what concerns the parents most FIRST. Deformities
Continually reassure the child during the exam and gain the child's trust. Encourage Contusions (bruising)
the parents to assist with the physical examination. Abrasions
Head Punctures/Penetrations
Gently palpate the head and feel for any skull irregularities or soft, spongy areas. Burns
Feel for crepitus (bone crunching sound). If any of the aforementioned are present
Tenderness
the child should be considered critical.
Lacerations
In infants the "soft spot" should be carefully examined. A bulging soft spot with a Swelling
history of trauma can indicate increased intracranial pressure. A bulging soft spot
with a history of 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
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 (bruising) beneath the eyes which is a sign of
base of skull fracture.

If there is an injury to either of the eyes, BOTH eyes should be dressed. This helps reduce
the movement of the eyes.

Nose

Check the nose for deformity or if there is any clear, straw-colored fluid (CSF - cerebro-spinal
fluid)or blood draining from the nose. If you suspect CSF is leaking the child should be
considered to be critical.

Mouth

Although the mouth should be checked under airway and breathing, reassess for any soft
tissue damage or damaged teeth. Do not stick anything into the child's mouth.

Assess the mouth for dryness which may be a sign of dehydration or hypovolemic shock.

Ears

Examine the ears for any leaking blood or CSF. Ecchymoses behind the ears is a sign of base
of skull fracture.

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 Neck

The child's trachea should be midline. If the trachea is deviated to either side (a sign of potential tension
pneuomthorax caused either by trauma or severe asthma) the child should be immediately reassessed for
respiratory difficulty.
Although difficult to detect in smaller children, distended neck veins may present in the case of 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 put the child at risk for altered mental status, respiratory distress and
shock.
If trauma is suspected, have cervical spine support maintained while gently feeling the back of the neck for any
tenderness, deformity or crepitus - all of which may indicated spinal injury. If a cervical spine injury is suspected
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 signs of respiratory distress if any of the above are present.
Auscultate the heart for any irregular or extra sounds e.g. murmurs, skipped beats, clicks etc
Auscultate the chest for breathing sounds over all the appropriate points. Take note of any wheezing, Rhonchi or
crackles. Make sure that the breathing sounds are equal bilaterally. If the sounds are unequal pneumonia,
pneumothorax or tension pneumothorax may be present.

Abdomen

Check the abdomen for DCAP-BTLS.

Use care when palpating the abdomen 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 results in the abdomen being distended. An abdomen
swollen from swallowed air is indicated by an enlarged left upper quadrant where the stomach is situated. The
enlarged stomach put pressure on the diaphragm making it more difficult for the child to breath.

Pelvis

Check the hip bones for DCAP-BTLS

Check the pelvis for stability taking note of any abnormal looseness or crepitus.
If the pelvis is unstable, reassess the child for signs of shock.
The mechanism of injury required to fracture a pelvis requires significant force and a high index of suspicion for
additional injuries should be maintained.

Genitals

If the child has any complaints in the genital area, assess for DCAP-BTLS.

Extremities

Check radial pulses, capillary refill and warmth 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 be threatened and the child's condition is urgent and must be rapidly transported to hospital.
Check motor function and nervous reflex in all extremities.
Check the extremities for DCAP-BTLS
Compare the extremities being examined to one another, take note of any difference or deformities. If there is
any deformity, tenderness or ecchymoses the limb should be immobilized.
If the movement 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 fracture is almost
always has accompanying ecchymoses.

Back

Check the back for DCAP-BTLS.

If there is any tenderness, ecchymoses or crepitus present the child should be immobilized.
If a spinal injury is already suspected, 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 any other abnormality.
Check any area that the child complains is painful.
Be alert for signs of child abuse (such as ecchymoses in unusual areas) or disease. If abuse is suspected it must
reported to the medical staff at the receiving hospital.
Gently assess the turgor of the skin by pinching a fold of skin to see if remains "tented" when released. If the
skin does remain 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 fluid for resuscitation for children is an
almost impossible task, especially when faced with the stress and pressures of a pediatric patient. A length-based
resuscitation device should always be used when drug interventions are required.

The tape should be used as follows (always follow the manufacturers instructions):

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 the heel of the child's foot should be used to estimate 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 and can be disinfected.

The Broselow Tape is a practical way to estimate the child's weight by measuring his length. 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 large or too small (the tape provides a guideline only).

Transport
This is the primary goal of prehospital emergency care, to stabilize and safely transport the patient to the 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 that warrant
spinal immobilization. If the child will require ongoing ventilations such as assisted ventilations or CPR the child should
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 adult faces, but should the parents be overly distraught
they should be transported to the hospital in a separate vehicle by a person who is in a sound enough condition to drive
safely (in other words don't let a distraught parent get behind the wheel).

All initial assessment findings should be forwarded to the receiving medical facility in order 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. Your patient documentation will
provide valuable insight to the hospital staff on exactly which interventions or treatments need to be performed. The
documentation should be free of personal opinions.

All interventions and the patient's response to those interventions should also be recorded.

The following is a general guideline on the information that should be included:

1. First impression
2. Findings during the initial assessment and the interventions performed
3. Findings from the focused history (if taken)
4. Vital signs including the times they were taken
5. Finding during the physical examination
6. All treatments and the patient's response to those treatments
7. All findings from reassessments, as well as reasons for any reassessments e.g. you noticed the skin color change

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 and decided to reassess the child's oxygenation.

Conclusion
Children provide unique challenges due to their specialized physiological, psychological and emotional needs. Often
rescuers are not equipped to deal with pediatric cases due to either insufficient training or little or no experience with
children. By obtaining a sound knowledge of children's physical and emotional development, the task of caring for
children will be that much easier and less stressful for all parties involved.

Author Michael Klopper, Copyright © CE Solutions. All rights reserved.

References
Pediatric Prehospital Care, David S. Markenson, M.D., F.A.A.P., EMT-P, Brady
Emergency Care In The Streets, 5th Edition, Nancy L. Caroline, Lippincroft, Williams and Wilkins
Paramedic TRIPP (Teaching Resources for Instructors in Pre-Hospital Paramedics

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