Infants, children, adolescents, and young adults create a unique population for health care providers. The initial approach to the pediatric patient should include creating a rapport with the child and parent, performing a primary examination, and developing a plan for treatment. The examination of a fussy child or a child who has special needs is particularly challenging. Awareness for the specialized pediatric patient interaction will go far in helping to get a good history and physical examination. The developmental changes throughout childhood will also impact the examination findings and major milestones should be noted as part of a history and normal examination (Table 49-1). Distinct anatomical and physiological differences distinguish the pediatric patient from the adult patient, creating a challenging clinical situation if the provider is unprepared. Notable increases in pediatric morbidity and mortality from trauma and respiratory complaints in tertiary care centers in the 1980s were directly related to a lack of specialty trained pediatric emergency providers. Multiple studies have confirmed these findings and in the late 1980s and 1990s more focus was devoted to developing pediatric emergency care training, curriculum, and prevention efforts (need references). Over the last several years there has been an explosion of pediatric critical care and pediatric emergency medicine literature that supports the field and its development. Our goal for this chapter is to provide a resource for basic pediatric assessment and intervention that will enable stabilization of the patient until a higher level of care is available.

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  List normal ranges for vital signs in different pediatric age groups.

  
  
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  Describe key physiological differences in pediatric patients relating to the prehospital care of medical emergencies.

  
  
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  Describe key physiological differences in pediatric patients relating to the prehospital care of trauma-related emergencies.

  
  
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  List appropriate resuscitation fluid types, amounts, and rates for different age groups and indications.

  
  
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  List drug doses for drugs commonly used in the prehospital environment.

  
  
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  Briefly discuss RSI and the drugs used for sedation and paralysis in children, with a focus on differences from standard adult care.

The unique differences between infants, children, and adults will guide the assessment and treatment of these patients. Three components of pediatric initial assessment include the Appearance of the child, the child’s Breathing, and an assessment of their Circulation by evaluating their skin (Figure 49-1). The combination of these ABCs allows for quick triage and emergent action if needed.

Pediatric care in the prehospital environment presents unique challenges for providers and medical directors.¹⁰ The nature of the developing anatomy and physiology lends to complicated assessment considerations and the need for special equipment and skills. In order to address these issues Emergency Medical Services for Children Program was created under the Emergency Medical Services for Children (EMSC) Act of 1984.¹¹ The program brings together a multidisciplinary group of experts and under the management of the US DHHS’s Health Resources and Services Administration (HRSA) and the US Department of Transportation National Highway Traffic Safety Administration (NHTSA).

TRANSPORTATION

The assessment and care of pediatric patients in the prehospital environment requires that providers have knowledge of age-specific physiology and stages of development, but also requires that EMS providers are properly equipped with the appropriate tools to safely and effectively evaluate, treat, and transport pediatric patients to appropriate destination facilities.

Because pediatric transports account for 4% to 13%¹ of transport volume in most EMS systems, and around 10.5%² of those transports involve care for seriously injured or ill pediatric patients, the care of pediatric patients could and should be considered to be a high risk but low volume event. As such, any tools that can assist the EMS provider in their accurate assessment of pediatric patients should be implemented by the EMS system. Such tools include pediatric weight or size-based drug dosage reference tables, as well as length-based pediatric assessment guides such as the Broselow Pediatric Emergency Tape.³ Such assessment guides help providers rapidly identify or calculate weight-based doses of critical drugs or to identify which size-based pieces of equipment like endotracheal tubes, laryngoscope blades, or intravenous catheters are appropriate to use in the care of pediatric patients.^4–6

Most states or jurisdictions have established minimal equipment standards that dictate the pediatric-specific equipment that is required to be carried by EMS vehicles in the jurisdiction. Additionally, several organizations, including NAEMSP, Emergency Medical Services for Children, ACEP, and the American College of Surgeons (ACS) have published recommended pediatric equipment guidelines for ambulances. In most EMS systems, it is probably not practical for EMS providers to carry a single “first-in bag” that contains all of the equipment and supplies needed to care for both pediatric and adult patients. Such a bag would be prohibitively large and heavy due to the need to carry several sizes of endotracheal tubes, laryngoscope blades, and other size- or pediatric-
specific items. Some systems may find it more practical and effective to equip their providers with specific pediatric equipment bags. Ideally, these bags would be similar to the standard adult “first-in bag” with regard to the cohorting and placement of certain pieces of equipment or supplies (airway, vascular access, etc). However, the pediatric bag should also be easily distinguished from the adult bag in order to avoid situations where inappropriate equipment is brought to a patient’s side.

PACKAGING

In 2010 NHTSA released “Recommendations for the Safe Transportation of Children in Ground Ambulances.” This document helped raise awareness that the sometimes common practice of transporting pediatric patients in the arms of caregivers who are secured to the ambulance stretcher is an unsafe practice. In a 2014 study by O’Neil et al, 14% of pediatric patients were transported in a parent’s lap, 14% were unrestrained, and none of the children under the age of 3 were properly restrained.⁷ Just as the civilian population must use a pediatric restraint device appropriate to a child’s size when children are being transported in a private vehicle, EMS providers should follow a similar practice (Figure 49-2). Fortunately, several options for safe restraint exist. In many situations, the EMS provider can simply ask to use a family’s own child restraint device while transporting the pediatric patient to a hospital. In situations where such a device is not available or practical to use, several manufacturers market devices specifically for use in the EMS environment to safely package pediatric patients of various sizes. Use of such devices reduces the need of EMS agencies to equip every transport vehicle with the wide variety of civilian child restraint devices that would be necessary to transport children of any size or age.

INTERFACILITY TRANSPORT

In addition to helping ensure that field providers are properly equipped, EMS physicians will also play an important role in developing pediatric care protocols, as well as developing guidelines to direct the dispatch of appropriately equipped and trained providers for execution of interfacility transport of pediatric patients. Depending on the EMS agency field provider and equipment resources, it may not be safe for a particular agency to perform interfacility transport of certain pediatric patients. Such circumstances are ideally defined in a prospective fashion and are detailed in a pediatric transport approval algorithm such as that depicted in Figure 49-3. In some cases, it may be beneficial or desirable to 
establish relationships with facilities that provide specific pediatric interfacility transport teams. In such circumstances, an EMS agency might provide the transport vehicle, but the receiving hospital would provide the equipment and pediatric critical care providers that are necessary to affect the safe and efficient transfer of critically ill neonatal or pediatric patients.⁸

TERMINATION OF RESUSCITATION

Just as pediatric patients require a different approach to assessment and treatment in the field due to age-related injury and illness patterns, there are some circumstances that occur in both the pediatric and adult population that will require a different operational approach by the EMS provider. Two examples include consent for treatment or refusal of care and withholding or termination of resuscitation in the field. The EMS physician should be familiar with the regulations in their specific operating jurisdiction regarding parental consent and refusal of care for pediatric patients. Chapter 24 provides more discussion of this topic.

Fortunately for patients, parents, and providers, EMS dispatches that result in the need to provide care for children in cardiopulmonary arrest are infrequent. However, unfortunately such circumstances do occur, and must be addressed prospectively with the development of appropriate protocols and guidelines. In these cases, protocols that have been developed to guide EMS providers in the decision to withhold or terminate resuscitative in the efforts for adult patients in cardiopulmonary arrest may not be appropriate to extrapolate to the pediatric population. Because of the significant social and psychological issues that caregivers are likely to experience during the critical illness or potential death of a child, it may be both reasonable and prudent for EMS systems to provide more aggressive field care and interventions than they would otherwise provide for an adult patient under similar circumstances. This care is likely to involve transport of children with no reasonable chance for survival to a hospital except in cases where there are obvious signs of prolonged death. Performing transport in these cases may allow for the engagement of specific social services and other support resources that will be necessary for family members or caregivers, and may provide more reassurance to both caregivers and EMS providers that “everything possible was done” to attempt to revive the child. In essence, EMS physicians and providers must recognize that in situations involving pediatric cardiopulmonary arrest with no chance for survival, provisions must be made for the care of the dying child as well for any family members or care givers who will almost certainly be affected by such a tragic event. It is necessary to note though that special care should be taken to both recognize and to not disturb evidence of potential child abuse or neglect in cases of out-of-hospital death of pediatric patients.

Pediatric respiratory distress is a common presenting complaint in the emergency setting. If treated improperly, even mild respiratory distress can quickly develop into an acute respiratory emergency that has significant morbidity and mortality. The initial assessment of the child with a respiratory complaint includes airway evaluation for patency, work and quality of breathing, and an assessment of circulatory compromise from respiratory failure. Due to the immaturity of the central respiratory control younger infants and children are less likely to provide an adequate and sustained ventilatory response to a respiratory emergency. The patency of the airway must be established at the outset of evaluation. If there is a concern for obstruction, the examiner must evaluate for partial versus total occlusion of the airway. If a child has a partial airway obstruction, administer supplemental oxygen and maintain a position of comfort with all efforts directed to decrease worsening respiratory function. A complete airway obstruction will require back blows for a child less than 1 year old or repeat abdominal thrusts in a child after the first year of life. The method of blind finger sweep is no longer advocated but the use of Magill forceps under direct laryngoscopy remains an adjunct intervention for removal of an airway obstructed by a foreign body.