General Approach
Children are not just small adults. Pediatric patients include a spectrum of children up to 18 years of age: newborns, neonates, infants, toddlers, preschoolers, school-age children, preteens, and adolescents. Their anatomy and physiology constantly change as they grow, as well as their emotional disposition and comfort with the healthcare system. Children account for about 20% of all emergency department (ED) visits with a large proportion of children 4 years or younger, so it is vital that the ED environment be child friendly and child safe. Children are almost always accompanied by an adult when presenting to the ED and family should be allowed to stay with the child whenever possible. Be sure to inquire what name to call the child, and then address the child by name. As the ED technician (EDT), you may be the first provider in the ED who interacts with the patient and family, so displaying competence and compassion is critical to set the stage for a successful visit.
Privacy is important regardless of the age of the child. Always use nonmedical terminology when speaking with the child and parents or caregivers so that all involved will comprehend results, interventions, and treatment. Be sure to acknowledge and compliment the child’s good behavior by encouragement and praise. Stickers or books can be used as rewards for good behavior. Allowing the child to make simple age-appropriate choices, such as which arm to use for measuring blood pressure, allows the child a sense of control in a medical situation that most likely will provoke anxiety. Encouraging the child to play during the examination and any procedures may have a calming effect. Diversion techniques, such as blowing bubbles to blow the hurt away or singing a favorite song with parents and caregivers are methods that provide distraction. As the EDT, you might ask older children to visualize a favorite place and describe it in detail with all five senses. Remember to give the child permission to express any feelings, reminding them it is “OK to cry.” Be mindful of what you might say aloud in the presence of an awake or presumed unconscious child, just as you would with an adult. Empathy is essential when caring for children.
When providing treatment for a child, interactions with the family play a fundamental role in the ED experience. Effective communication with family members facilitates obtaining an accurate history so optimal care can be delivered. Often family members will exhibit significant anxiety and emotional stress, especially if the child is injured or ill. The reaction of the parent or caregiver will directly affect how the pediatric patient behaves and how the ED team approaches the patient. In situations such as these, providing a supportive environment is critical for cooperation from the family and the patient. The presence of the family during procedures has been shown to decrease patient stress, and evidence indicates that family members do not interfere with the duties of healthcare providers. It is important to assess first whether the family member will be able to cope with the events that might occur during the procedure.
Initial Assessment of the Pediatric Patient
Children who are ill and potentially critical present differently than adults, so it is essential to recognize when a child requires urgent attention. The Pediatric Assessment Triangle (PAT) is an assessment tool that should be performed prior to the physical examination (see Fig. 24.1 ). The PAT is a 15- to 20-second evaluation that assesses general appearance, work of breathing, and circulation to the skin. This efficient method determines whether a patient is critically ill. If one of the three components of the PAT is abnormal, then the EDT should alert a nurse or physician immediately.
Physiologic Differences
In neonates, presenting symptoms are vague, nonspecific, and subtle. Many visits are due to parental concerns related to feeding, weight gain, stooling, breathing patterns, and sustained crying. Physiologic differences compared with adults that are important to recognize in neonates and infants include the following:
Larger head-to-body ratio
Faster relative heart rate
Lower relative blood pressure
Larger tongue
Hyperextension of neck easily obstructs airway
Chubby arms and legs so difficult to place intravenous (IV) line
Body heat lost more easily
Normal Vital Signs
Vital signs are the purview of the EDT. You may be expected to obtain vital signs and report abnormal findings to the nurse or medical provider. Abnormal findings may indicate critical illness in the patient, so it is important to recognize both normal and abnormal vital signs in the pediatric patient. As children grow and develop, their vital signs change. Table 24.1 summarizes normal vital signs.
| Age | Respiratory Rate | Heart Rate | Systolic Blood Pressure |
|---|---|---|---|
| Newborn | 30–60 | 120–160 | 50–70 |
| Infant (1–12 months) | 25–30 | 100–150 | 70–100 |
| Toddler (1–3 years) | 20–40 | 90–130 | 80–110 |
| Preschool (3–5 years) | 20–30 | 80–120 | 80–110 |
| School age (6–12 years) | 18–30 | 70–110 | 80–120 |
| Adolescent (13+ years) | 12–16 | 60–105 | 100–120 |
The Pediatric Advanced Life Support formula for the 50th percentile of blood pressure is 90 + (2 × age in years). A normal newborn blood pressure is 60 mm Hg.
The rare event of pediatric cardiac arrest is most often the result of respiratory failure, so respiratory rate and oxygen saturation are crucial measurements in every child.
Intravenous Access
IV access in pediatric patients can be extremely difficult and will depend on the skill level of the EDT. Placing an IV in children is frequently made challenging by anatomic factors such as vein size and mobility and limited patient cooperation where the child may move, cry, or pull away from the technician.
Before attempting IV access on a pediatric patient, an EDT must be proficient with obtaining IV access in adult patients. Placing an IV should not constitute an episode that might cause psychological trauma to the pediatric patient. Using a child life specialist to ease discomfort during ED visits and educate children on health issues and topics is extremely helpful. Child life specialists are pediatric healthcare professionals who work closely with children and their families to help everyone cope with medical procedures, pain, and other challenges in the hospital setting. Their job is to provide children with age-appropriate preparation for painful medical procedures and coping strategies.
To cultivate trust, an EDT must be honest with the patient. If the child is old enough to understand why the procedure must be done, then the following language can be used in the explanation: “After the needle comes out, there is just a plastic straw that stays in your body and the needle does not stay in your skin.” Always ensure there is a parent or guardian present for the procedure with a nurse or other helper to safely keep the patient still while you attempt IV access. Many EDs use topical anesthetics (e.g., EMLA) applied to the skin site 20 minutes prior to insertion of the IV to reduce pain. Unlike the usual IV antecubital fossa access in adults, optimal access in children may be found in the forearms, wrists, and hands. When attempting to locate venous access, the use of an LED-based transillumination vein finder may be a useful solution ( Fig. 24.2 ).
