Emergency Care of Children

INTRODUCTION

Children are not just small adults. This standard mantra is heard in EDs around the world. About one third of all ED visits are by children. Anatomic, physiologic, and developmental differences between children and adults give rise to a unique epidemiology, pathophysiology, and differential diagnosis. Key elements of the medical history must often be elicited from caretakers, not from the child. It may be difficult to perform a physical examination on a child, and cardinal signs of disease are different in children compared to adults. Diagnostic testing can cause pain or potentially long-term harm. Drugs require weight-based dosing, and equipment selection must be tailored to the child’s size. Disposition may require transfer to a specialized children’s hospital. Finally, even though the child is the primary patient, management must be family centered and often involves addressing the fears and stresses of family members.

ANATOMY AND PATHOPHYSIOLOGY

Pediatric age groups are divided into neonates (birth to 1 month), infants (1 month to 1 year), toddlers (1 to 3 years), school-aged children (3 to 12 years), and adolescents (12 to 18 years). Significant developmental and physiologic changes occur across these age groups; Table 106-1 summarizes the developmental milestones as they relate to the ED evaluation and approach, and Table 106-2 lists the age-dependent vital signs.

TABLE 106-1 Pediatric Developmental Stages and ED Assessment

Stage	Milestone	Strategy
Early infancy (0–6 mo)	Motor: lifts head, reaches	Observation
	Verbal: cooing	Examine in parent’s arms
	Social: responsive smile	Direct approach
Late infancy (6–18 mo)	Motor: reaches/obtains, sits, walks	Observation
	Verbal: jargon, few words	Examine in parent’s arms
	Social: stranger anxiety/dependence	Indirect approach
Toddler (18–36 mo)	Motor: walks well, scribbles	Observation
	Verbal: speaks in phrases	Indirect approach
	Social: stranger anxiety/autonomy
Preschool (3–5 y)	Motor: runs well, colors	Indirect or direct approach
	Verbal: speaks in sentences	Explain briefly just before procedures
	Social: magical thinking
School age (5–12 y)	Motor: schoolwork, sports	Direct approach
	Verbal: concrete reasoning	Explain in detail before procedures
	Social: task oriented
Adolescence (12–17 y)	Motor: adult	Direct approach
	Verbal: abstract reasoning	Confidentiality
	Social: autonomy, rebellion	Treat as adult

TABLE 106-2 Pediatric Vital Signs by Age (Awake and Resting)

Age	Heart Rate, Upper Limit (beats/min)	Respiratory Rate, Upper Limit (breaths/min)	Blood Pressure,^* Lower Limit (mm Hg)	Weight,^† (kg)
0–1 mo	180	60	60/40	3–4
2–12 mo	160	50	70/45	5–10
12–24 mo	140	40	75/50	10–12
2–6 y	120	30	80/55	13–25
6–12 y	110	20	90/60	25–40
>12 y	100	20	90/60	140–60

Neonates undergo the most profound changes as they transition from metabolic and respiratory dependence on the placenta to independence as air-breathing beings. The cardiovascular and respiratory systems switch from near complete shunting of blood flow away from the lungs to typical adult circuitry and dependence on the lungs for oxygenation as the ductus arteriosus closes (see chapter 126, “Congenital and Acquired Pediatric Heart Disease”). Oxygen-avid fetal hemoglobin changes to adult hemoglobin with predictable changes in hemoglobin levels throughout the first years of life. The neonatal and infant immune systems depend on passive maternal humoral protection transferred through the placenta and breast milk until cellular and humoral defenses mature. Immunologic immaturity predisposes to bacterial and viral systemic infections early in life. The neurologic system is characterized by rapid growth, differentiation, and myelination and changes in the balance of excitatory and inhibitory neurotransmitters, which account for susceptibility to seizures.

Anatomically, growth and development of every organ system characterizes infancy and childhood and affects emergency care across the life span. A relatively large occiput, small jaw, high and anterior larynx, narrow cricoid cartilage, and large tongue require unique considerations in airway management (see chapter 111, Intubation and Ventilation in Infants and Children). A soft, compliant chest wall, obligate nose breathing, and gastric inflation from swallowed air alter the mechanics, symptoms, and signs of respiratory distress in young children. Neonates, infants, and children increase cardiac output through an increase in heart rate rather than stroke volume. Tachypnea, an increased rate of breathing, not hyperpnea, an increased depth of respiration, is the primary respiratory compensatory mechanism. The musculoskeletal system of young children differs from that of older children and adults not only in its proportions (e.g., relatively large head), but also because ligaments are stronger than bones, predisposing to fractures rather than sprains. Linear growth of long bones occurs from specialized cartilaginous end plates (physes), which results in unique fracture patterns (see chapter 140, “Musculoskeletal Disorders in Children”).