Chapter 35. Assessment of the paediatric patient
The aim of the prehospital assessment is management of the child’s condition rather than specific diagnosis.
The age of a child is usually known but the weight must sometimes be approximated by the formula:
This works well between the ages of 1 year and 10 years.
The average birthweight of a full-term infant is 3.5 kg; this has usually doubled by 5 months of age and tripled by 12 months.
| Age | Weight (kg) |
|---|---|
| 2 months | 5 |
| 6 months | 7.5 |
| 1 year | 10 |
| 3.5 years | 15 |
| 6 years | 20 |
| 10 years | 30 |
| 13 years | 40 |
| 14 years | 50 |
Immediate assessment
The SAFE approach should be used. Children are usually easy to move to a safer place.
Airway
Check for responsiveness. Failure to respond indicates a significantly lowered level of consciousness and therefore an airway at risk. There may be a need for airway opening manoeuvres and action to protect the airway.
Partial upper airway obstruction is suggested by snoring, rattling or gurgling.
Stridor is heard best in inspiration – this differentiates it from wheezing, which is usually loudest in expiration. Stridor suggests obstruction at the level of the larynx and upper trachea and can be caused by a foreign body or by infection (usually associated with fever).
Do not examine the throat with any instrument in children with stridor or suspected partial airway obstruction – doing so may convert the problem to complete obstruction
Drooling, the inability to swallow saliva, suggests blockage at the back of the throat.
Cyanosis and reduced haemoglobin saturation readings on a pulse oximeter are very late signs of airway obstruction
All children will benefit from high-concentration oxygen therapy. Only a small group of infants with congenital heart disease need controlled oxygen therapy.
It is not worth struggling to make an unwilling child wear an oxygen mask
If a child’s airway can be maintained by simple manoeuvres, an oropharyngeal (Guedel) airway is best avoided. This is because retching is easily induced in children and may be followed by laryngospasm or aspiration.
• Oropharyngeal airway size = the distance from the centre of the lips to the angle of the jaw
• Nasopharyngeal airway size = the distance from the tip of the nose to the tragus of the ear Endotracheal tube size:
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Assess the need for cervical spine protection before any airway intervention
Breathing
Look, listen and feel for breathing. The absence of breath sounds indicates the need to follow procedures for cardiorespiratory arrest.
Look for:
• Difficulty in talking – a child who is unable to speak because of laboured breathing is very unwell
• An abnormal respiratory rate – usually fast, laboured breathing. Very slow respiratory rates may occur just before respiratory arrest or in children poisoned with narcotic drugs
• Recession of the chest wall – the indrawing of the elastic tissues of a child caused by increased respiratory effort
• Wheezing and rattling, grunting and panting
• Nasal flaring and use of the shoulder and neck muscles during breathing
• Unequal or diminished breath sounds.
| Age (years) | Respiratory rate (breaths/min) | Pulse rate (bpm) |
|---|---|---|
| Under 1 | 30–40 | 110–160 |
| 1–5 | 25–30 | 95–140 |
| 6–12 | 20–25 | 80–120 |
Absence of breath sounds means that the movement of air in the lungs is so diminished that it cannot be heard
All the above suggest that the child is struggling to achieve normal respiration. Failure to adequately oxygenate the blood and hence the tissues, is shown by:
• Tachycardia – the hypoxic nervous system is stimulating the heart
• Cyanosis – a late sign
• Irritability, confusion or reduced responsiveness mean that the brain is short of oxygen – this is an extremely worrying sign.
The oxygen saturation shown by the pulse oximeter should be close to 100% in a normal, healthy child
All wheezy children will benefit from nebulised bronchodilators, whether they are known to be asthmatic or not. Agitation, tachycardia and tremor may be signs of salbutamol overdosage. Ventilation is indicated as an emergency procedure for respiratory insufficiency in a child in the same way as in an adult, suggested ventilator settings for children are:
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