Lecture 3: Pediatric Considerations

Objectives

On completion of this module, the EMA/Paramedic will be able to:

describe the components of the pediatric acuity assessment

perform an assessment on a pediatric patient and assign an appropriate acuity level using the CTAS acuity scale

discuss the considerations required to assign an acuity level to the pediatric patient

Use of EMS by Pediatric Patients

fewer than 10% of requests for medical services are for children

caregivers often choose to transport their critically or seriously ill or injured child to an emergency department by private vehicle rather than waiting for emergency medical services to respond.

– Reference: Institute of Medicine, Division of Health Services, National Research Council

Unique Attributes of the Pediatric Patient

children are not small adults, (it’s the other way around)

differences include size, thought processes, physical and emotional maturity and social development.

Pediatric Considerations

children are less likely to have life threatening conditions

symptoms of life threatening problems may be subtle and progress rapidly,and

frequently involve the respiratory system or central nervous system

Pediatric Considerations

accurate assessment is critical due to the potential for rapid deterioration

the child’s diagnosis is not as important as recognition of the potential for rapid deterioration based on history and physical findings

•a physiologic assessment of the child will assist in assigning the acuity level •patients with abnormal vital signs- heart rate or respiratory rate, are level 1 or level 2

Pediatric Considerations

Components of the Pediatric Assessment

• pediatric assessment triangle• pediatric history (subjective data)• physical assessment (objective data)

Pediatric Assessment Triangle

Appearance Work Of

Breathing

Circulation

Pediatric Assessment Triangle

General appearance– activity level– level of consciousness

Work of breathing– respiratory rate– respiratory effort

Circulation– heart rate– perfusion

The “Key Look”: Using sight, hearing, smell, and touch

non verbal cues: facial grimaces, fear, cyanosis listen for a cough, hoarseness, or labored breathing touch the patient, assess heart rate, skin

temperature and moisture, capillary refill assess for odors such as ketones, alcohol or

infection

Pediatric Physical Assessment:

• may be limited if patient requires rapid access to care/interventions (Level 1 & Level 2)

• all pediatric patients must have their general appearance, respiratory rate, effort and perfusion evaluated initially

• Note: age/developmentally appropriate behavior and social interactions

indications of child maltreatment (does the story make sense?)

Pain Assessment in Children

tachycardia, pallor, sweating and other physiological signs are also used to evaluate pain

pain scales are less helpful (or reliable) at the extremes of age

the parents can give an indication of the severity of pain pain perception may be influenced by age, past

experience and cultural differences

Pediatric Vital Signs abnormal vital signs are often a late

finding tachycardia is an early indication of

hypotension or hypovolemia abnormal VS

level 1 patients have VS- HR or RR > 2 SD level 2 patients have VS- HR or RR > 1 SD

Pediatric Vital Signs

______________________________________________________________________________Age Respiratory Rate ( RR) Heart Rate ( HR )

Normal +/-1SD +/-2SD Normal +/-1SD +/-2SDRange (NR) Range(NR)

Birth - 3 months 30 - 60 20 – 70 10 – 80 90 –180 65 – 205 40 - 230 months - 6 months 30 - 60 20 – 70 10 - 80 80 –160 63 –180 40 - 2106 months -1 year 25 - 45 17 – 55 10 - 60 80 –140 60 –160 40 -1801 year - 3 years 20 - 30 15 – 35 10 - 40 75 –130 58 –145 40 -165 6 years 16 - 24 12 – 28 8 - 32 70 –110 55 –125 40 -14010 years 14 - 20 10 – 24 8 - 26 60 – 90 45 –105 30 -120

______________________________________________________________________________

CTAS Level 1

Resuscitation

CTAS Level I: Explanation

• require aggressive treatment

• pre and post arrest

• unable to speak due to respiratory distress, cyanosis

• lethargic/confused

• tachycardia/bradycardia

• O2 saturation < 90%

•VS HR or RR > 2 SD

CTAS Level 1: Physiologic Assessment

• unresponsive• severe respiratory distress/inadequate

breathing • cardiac arrest/shock/cyanosis• respiratory rate greater/less than 2

standard deviations from normal range• heart rate greater/less than 2 standard

deviations from normal range

CTAS Level 1: Usual Presentations Severe respiratory distress

– airway compromise

– near death asthma

– anaphylaxis

– congestive heart failure

– pneumothorax

CTAS Level 1: Usual Presentations Major trauma

- head injury with GCS < 10

- severe burns (> 25% TBS or airway problem)

- spinal injury with neurologic deficit

Major Trauma:

–Chest/abdominal injury with any of:– i) hypotension and tachycardia, usually

with severe pain (pain scale 8-10), –ii) respiratory distress with abnormal rate,

volume, or decreased air entry, –iii) altered mental state suggesting

hypoxemia or hypoperfusion.

CTAS Level 1: Usual Presentations

CTAS Level 1: Usual Presentations Shock states:

– shock/hypotension/ tachycardia

– anaphylaxis

– septic

CTAS Level 1: Usual Presentations

Unconscious/unresponsiveness

– active seizures

– intoxications/overdoses

– hypoglycemia

– metabolic disturbances

- NB: All patients with altered mental state must have a rapid blood sugar screen test.

CTAS Level 2

Emergent

CTAS Level 2: Explanation

unstable child with moderate to severe respiratory distress with potential to deteriorate

altered level of consciousness

abnormal vital signs: VS -HR or RR > 1 SD<2 standard deviations

need for rapid treatment on arrival

controlled acts may have been applied in the prehospital setting (ALS)

CTAS Level 2: Physiologic Assessment

• altered consciousness• altered mental status: lethargic, drowsy,

agitated, inconsolable• moderate respiratory distress/marked

stridor• capillary refill greater than 4 seconds

CTAS Level 2: Usual Presentations Head injury

– GCS < 13– severe headache, loss of consciousness

>5 minutes, confusion, neck symptoms and nausea or vomiting

CTAS Level 2: Usual Presentations

Overdose

– intentional and unintentional

CTAS Level 2: Usual Presentations Fever

- age < 3 months

- temperature > 38.0 0 C

- immunocompromised

- chemotherapy

- chronic illness

CTAS Level 2: Usual Presentations Vomiting and/or diarrhea

- signs of moderate to severe dehydration

- altered level of consciousness

- capillary refill > 2 seconds

- hypotension

Moderate to Severe Dehydration

decreased capillary refill, tachycardia, decreased urine production, decreased skin turgor, dry oral mucosa, sunken fontanelle, and lethargy

CTAS Level 2: Usual Presentations Neonates

– less than 7 days of age

CTAS Level 2: Usual Presentations Child Abuse/neglect

- afebrile with altered level of consciousness

- history of ongoing risk

- unexplained trauma

CTAS Level 2: Usual Presentations Serious infections

- purpuric skin rashes ( non blanching spots)

- history of fever or chills with rigors

- temperature instability in neonates

- infants less than 3 months temperature < 36 or >38

- immunosuppressed and asplenic children

- infants more than 3 months with fever and a toxic appearance

Case Presentations

A 15 year-old male was hit by a car and fell from his bicycle. He denies loss of consciousness, headache, and neck pain. He complains of severe abdominal pain (8/10) mostly left upper abdomen. He is uncomfortable and grimacing with pain. V/S are pulse 110, B/P 124/68, respirations splinting and 18. GCS 15. He is tender in the LUQ. There are no obvious bony injuries.

You have attended a 4 year-old girl who is covered in hives, has stridorous breathing, audible wheezing, and is very anxious and distraught. She appears cyanotic and ashen. The mother states that the child ate a peanut butter cookie prior to the hives appearing. V/S initially, HR 120, RR 30. O2 is applied by NRB. You have given Epinephrine 0.2 ml. SQ with no response and are now en route to hospital.

A mother calls the ambulance for her 3 year-old son who has had a fever (39º C) for 1 day. The child has leukemia and is on chemotherapy. His last treatment was four days ago. The child has flushed cheeks but otherwise looks well. V/S are pulse 120, BP 100/65 and respirations 20.

You arrive and find a 2 month-old infant carried in his mother’s arms. He has had a “high” fever for 2 days and has been given Tylenol with some relief. Yesterday the baby was irritable and today the baby is not feeding well and is lethargic. The baby looks unwell and floppy. VS are pulse 200, RR 36. You apply O2 and transport immediately.

CTAS Level 3

Urgent

CTAS Level 3: Explanation

normal vital signs

presenting problem suggests a more serious acute process occurring

moderate pain(4-7/10) involving head, chest, abdomen

CTAS Level 3: Physiologic Assessment

• infant – inconsolable, not feeding or atypical behavior

• mild respiratory distress, mild stridor• respiratory rate at the limits of normal range• heart rate at the limits of normal range• capillary refill greater than 2 seconds

CTAS Level 3: Usual Presentations Head injury

- alert (GCS 13-15)

- moderate pain (4-7/10)

- nausea or vomiting

CTAS Level 3: Usual Presentations Moderate Trauma:

- head, chest, abdominal pain(4-7/10)

- patients extremity trauma - fractures or dislocations pain (8-10/10)

CTAS Level 3: Usual Presentations Asthma, Mild/moderate

- short of breath on exertion

- frequent cough

- O2 Saturation > 92 < 94 %

CTAS Level 3: Usual Presentations Dyspnea Moderate

- pneumonia

- bronchiolitis

- croup

CTAS Level 3: Usual Presentations Seizure:

– brief duration (< 5 minutes)

- known seizure disorder

- new onset

- patient stable and alert

- able to manage airway

- normal vital signs

CTAS Level 3: Usual Presentations Vomiting and/or diarrhea

< 2 years, normal vital signs, looks well

> 2 years, mild to moderate dehydration, stable vital signs, may look unwell

CTAS Level 4

Less Urgent

CTAS Level 4: Explanation stable vital signs

lower pain scales

patient can wait longer for primary care

most care givers would bring their child to ED

CTAS Level 4: Physiologic Assessment

Consolable/appropriate but history of atypical behavior

respiratory rate within normal range for age

heart rate within normal range for age

CTAS Level 4: Usual Presentations

Head Injury

- alert (GCS 15)

- no loss of consciousness

- no vomiting, may have headache (0-3/10)

- no neck symptoms

- normal vital signs

CTAS Level 4: Usual Presentations Minor Trauma

- extremity pain (4-7/10 )

- head, chest, abdominal pain (1-3/10)

- lacerations requiring investigations or interventions

- minor fractures

CTAS Level 4: Usual Presentations Abdominal pain

- history of acute pain (1-3/10)

- the severity of pain does not rule out a potentially serious problem

- patient should not appear distressed

- start by assuming the worst

CTAS Level 4: Usual Presentations Ear ache

- causes moderate (4-7/10) to severe pain(8-10/10)

- child may present in severe distress and may need pain management early and assigned a higher level

CTAS Level 4: Usual Presentations URI Symptoms

- may present with upper airway congestion, cough,aches, sore throat are more common presentations for children.

- fever

- a reminder that “flu” like symptoms can be serious for the younger population.

CTAS Level 4: Usual Presentations Vomiting and/or Diarrhea

- no signs of dehydration (age >2)

- simple viral gastroenteritis is usually benign

CTAS Level 5

Non Urgent

CTAS Level 5: Explanation often do not use ambulance

minor complaints

do not pose any immediate risk to the patient

degree of pain is minimal

CTAS Level 5: Physiologic Assessment

no history of atypical behavior

respiratory rate within normal limits for age

heart rate within normal range for age

CTAS Level 5: Usual Presentations Minor trauma

- contusions, abrasions

- lacerations not requiring suturing or closure

- minor sprains with minimal pain (1-3/10)

CTAS Level 5: Usual Presentations Vomiting alone, diarrhea alone

- no signs of dehydration

- afebrile

- normal vital signs and mental status (child is active and sociable, curious of surroundings)

You are encouraged to use your experience and instincts to “up triage” priority even it the patient does not seem to fit exactly with the facts or definitions on the triage scale.

“Not all patients are as sick as they appear, and not all patients are as well as they think.”

Case Presentations

A 15 year-old male was hit by a car and fell from his bicycle. He denies loss of consciousness, headache, and neck pain. He complains of severe abdominal pain (8/10) mostly left upper abdomen. He is uncomfortable and grimacing with pain. V/S are pulse 110, B/P 124/68, respirations splinting and 18. GCS 15. He is tender in the LUQ. There are no obvious bony injuries. Case #34

You respond to a track and field event. On arrival you note a 17 year-old male who has collapsed following what was reported as seizure activity. BP 114/52, HR 62 irregular, RR 22. GCS 15 and he is alert and orientated. He reports a similar event occurring a week ago at practice. Case #35

You respond to a call from the police dispatch centre. You arrive to find a 42 year-old male who is being restrained from jumping off the balcony of his apartment building. He states he is being told to jump. He has attempted suicide in the past. He has a history of manic depression and is on lithium. He is now restrained on an ambulance stretcher. Case #36

You are transporting a 2 year-old who swallowed a plastic Christmas star. She has vomited during your assessment and occasionally gags. She has no laboured respirations or stridor. Her chest is clear, and vital signs are normal. Case #37

You are called to a shopping center for a man collapsed. The gentleman was found to be VSA and after initial defibrillation, you have return of a perfusing rhythm and the patient awakens. You package him for transport and the patient’s condition is as follows: HR 80 and sinus on the monitor with no ectopy, BP 120/70, RR 18 and spontaneous, and GCS 13. Case #38

You respond to a call from the school nurse. You arrive to find a 13 year-old male sitting slumped in a chair. He appears tired avoiding eye contact. BP 112/60, P 108, respirations are rapid and deep at 24 breaths/minute. GCS 15, Blood Sugar is 30 mmol/L. His face is flushed and you do note an odour of acetone on his breath. Case #39

You respond to a call to a private residence. On arrival you find a 32 year-old female at the bottom of the cellar stairs. You note this woman to be in the advanced stage of pregnancy. You also note bleeding between the patient’s legs. GCS 15, BP 96/60, Pulse 118. The patient is moaning, not identifying specific areas of discomfort. Case #40

You respond to a call from the local community centre. You arrive to find a 28 year-old male sitting on a bench after having sustained an injury to his left elbow while playing hockey. He is complaining of pain in his left elbow with numbness to his left hand. BP 144/90, HR 100, RR 24. You note an obvious dislocation to the left elbow and are unable to palpate a left radial pulse. Case #41

You are dispatched to a residence for a patient experiencing chest pain and shortness of breath. Upon arrival you are presented with a 58 year-old male with a previous history of MI 3 year’s ago. Your assessment reveals chest pain rated as a 7/10, equal bilateral air entry, BP 160/90, P 110 regular and full, respirations 24 shallow and regular. Skin warm moist and pale. The patient has taken 2 NTG sprays prior to your arrival. You administer NTG spray and ASA. Enroute you administer 2 more NTG sprays. Case #42

You respond to a call from a nursing home. When you arrive you note a 79 year-old male who is incoherent and has a left-sided weakness. According to the nursing home staff he has always been fairly active, these symptoms were a sudden onset. BP 165/105, HR 82 irregular, RR 22. He is agitated and refuses to lie down and will only sit up on the stretcher. He also will not leave nasal prongs for oxygen delivery. Case #43

You respond to a residence and are met by a mother carrying her three-month-old child. The mother states that the child has been vomiting, and refuses to eat or drink anything. You note the child is breathing fast and respirations are difficult to assess, has a runny nose, cough, and a fever. The mother states the child is lethargic. The child is pale and limp in mother’s arms. Case #44

You manage a 32 year-old patient with a history of asthma and sudden onset of shortness of breath after exposure to a cat. She has audible wheezing and her initial V/S are HR 110, RR 32 and laboured, BP 130/70 and O2 sat 92%. You treat her with supplemental oxygen and with nebulized Salbutamol. After one treatment the patient feels much improved and questions if she needs to go to the hospital. After a discussion with the patient she agrees to go to hospitals and her V/S are HR 90, RR 22, BP 130/70, O2 sat 97%. Case #45

You are dispatched to a nursing home to transport a patient to the emergency department. You arrive to find a 92 year-old male who has been vomiting all night. He is pale, skin is dry and you note that the emesis is coffee ground colour. The patient is conscious although disoriented. BP 108/70, HR 96, RR 16. Case #46

You are dispatched to a local beach for a patient who has been stung by a bee. Upon arrival you are presented with a 14 year-old male patient who is short of breath with hives and facial swelling. He has obvious wheezes, BP 100 by palpation, P 100 weak and regular respirations, 24 shallow and irregular. You immediately administer 0.3mg of Epinephrine 1:1000 and begin a Salbutamol treatment 5 mg. Case #47

You are called to a residence of a 65 year-old man complaining of sudden onset of shortness of breath three hours ago. He denies CP. The patient has a history of angina and CHF. His VS are HR 96, RR 32, BP 188/112, O2 sat 92%, crackles to mid lung fields and no pedal edema. You manage the patient with positioning, oxygen, cardiac monitor and nitrates. After spending 15 minutes extricating the patient from his walk-up apartment his V/S are HR 92, RR 24, BP 164/96 O2 sat 96% and the patient states his shortness of breath has improved moderately. Case #48

You respond to a senior citizen’s group home where you find an 80 year-old female who has sustained a fall. She states the floor was wet and she slipped. You note that her left leg is shortened and outwardly rotated. She keeps rubbing her left hip area stating it is quite painful to move. She only takes a water pill every other day. V/S are BP 165/90, HR 90, RR 18, pedal pulses are present in her left leg. She is immobilized and transferred onto the stretcher. Case #49

You are dispatched to a local arena for a patient short of breath. Upon arrival you are presented with a 27 year-old male in obvious distress. You learn that the patient is a known asthmatic and has tried his puffer with no relief. BP 130/80, P120 weak and regular, respirations 26 shallow and irregular skin- pale cool and moist. You immediately administer 5 mg. of nebulized Salbutamol with a second treatment enroute. Case #50

You arrive at a residence of a 28 year-old woman with known diabetes for who is comatose (GCS 8), HR 110, BP 120/60. You find her capillary glucose to be 2 mmol/L. After treatment the woman has regained consciousness (GCS 15), HR 80, BP 120/60. You prepare for transport. Case #51

You arrive and the mother states that her 18 month-old child has had a fever, vomiting and diarrhea for 2 days. He was at the after hours clinic last evening and told to continue with Tylenol and fluids. This morning the child “looks sick.” The child has not voided overnight. His pulse is 145, respirations 35. You apply oxygen and transport. Case #52

A 39 year-old female was on a ladder fixing her windowsill and fell eight feet onto her patio deck. She landed on her back, had no LOC. She has no obvious injuries and her only complaint is lower back pain. No medical history. She is unable to move or feel her legs. BP 130/84, P 90's and regular, respirations 16, full and regular. Case #53

A 9 year-old female complains of a right earache that started earlier today. She was given Tylenol with some relief. She is tearful and having pain (7/10). Vitals are temperature 37.9º C, pulse 80, and respirations 16. Case #54

You respond to a school where you are directed to the health nurse’s room. A 16 year-old is accompanied by his football coach. His coach states that his player was tackled and now has severe abdominal pain. His colour is pale, he is diaphoretic and his V/S are BP 90/54, pulse 108, respirations 22. A large bore intravenous is started with N/S tkvo. Case #55

You are dispatched to a residence for a patient experiencing chest pain. Upon arrival you are presented with a 68 year-old male patient who has taken 3 NTG with some relief. BP 140/90, P 88 reg. and full, respirations, 16 deep and regular, skin pale warm and dry. You administer 1 NTG at the scene and begin transport. In the ambulance you administer 2x80mg ASA and a second NTG. Approximately 5 min. from the hospital the patient says he feels very strange and becomes unconscious. Your assessment reveals the patient to now be VSA. You attach your defibrillator and administer 2 shocks and have a return of spontaneous circulation. Case #56

You respond to a call from a school. You arrive to find a 6 year-old girl who is crying. The teacher states that she fell in the schoolyard and struck the side of the sandbox. The girl’s face is covered with dried blood and she has not stopped crying. You note the child is alert and crying, respirations are unlaboured and she is pale. You also note a deformed right forearm. The arm is splinted and you note a 4-cm. laceration above the left eyebrow once the face is cleaned. V/S GCS 14, P 120, respirations 18, BP 100/56. Case #57

You respond to a residence where you find a 46 year-old female who has a decrease level of consciousness and who is in respiratory distress. She has a history of ovarian cancer and has been on palliative care at home. Although her wish was to stay at home her family is requesting she be brought to the emergency department because her “breathing has changed.” She is pale, diaphoretic and cool to touch. Her extremities are cyanotic. She has a saline lock for analgesic administration and she receives oxygen at 4L/minute via nasal prongs. V/S are BP 110/72, Pulse 86, respirations 32. Case #58

You are dispatched to a residence for a patient complaining of SOB. Upon arrival you are presented with a 70 year-old male patient with a 15-year history of COPD. The patient tells you that he has been more short of breath than usual over the past day. You observe noisy breath sounds on auscultation with decreased air entry. BP 140/90 P 88 regular and full, respirations 24 shallow and irregular. You administer Salbutamol 5 mg. Case #59

You are presented with a 26 year-old male, feeling depressed, not suicidal. He has a history of mental illness. He denies taking pills or alcohol. Vitals are normal. Case #60

You are dispatched to a scene in an industrial area. On arrival you note a 24 year-old male who has been assaulted. He has several facial lacerations and his left eye is swollen shut. The bleeding is controlled. He denies any loss of consciousness. He is alert and orientated. BP 166/90, HR 102, RR 20. GCS 15. Case #61

You respond to a call from a 30 year-old female who states she has taken a large amount of Tylenol capsules. She is orientated, alert and her V/S are BP 110/62, HR 88, RR 14 and GCS 15. She changes her mind about going to the hospital and after some encouragement from her roommate she finally consents to going to the emergency department. Case #62

You respond to a call to a private residence. On arrival you find a 63 year-old, in a state of undress sitting on the steps leading into the home. The patient is leaning forward and you note he is displaying indrawing intercostal muscles and prolonged forced expiratory phase. The patient responds to questions asked with one-word answers. You note an unlabeled inhaler by his side. BP 148/88, respirations 14, P 76. Case #63

You arrive at a home where you are met by a mother carrying a 1 year-old who fell off the changing table only moments ago. The baby is alert, sociable and sucking on his bottle. On examination it is noted that he has a reddened temporal area. Case #64