Chapter 53The special needs of children
Susan Fuchs
Epidemiology of prehospital pediatric care
Despite the fact that pediatric calls account for only 13% of ambulance runs [1], they provoke a disproportionate degree of concern and anxiety for prehospital care providers and, in turn, medical oversight physicians. A recent study by the Pediatric Emergency Care Applied Research Network (PECARN) from 14 EMS ground agencies across 11 states found that the most common chief complaints were traumatic injury (29%), general illness (10%), respiratory distress (9%), behavioral/psychiatric disorder (8.6%), seizure (7.45%), pain/non-chest/non-abdomen (6.5%), abdominal pain/problems (4.5%), and asthma (3.9%) [2] (Table 53.1) [3].
Table 53.1 Top three chief complaints by age [3]
<1 year | 1–5 years | 6–12 years | 13–18 years |
Respiratory distress (27.2%) | Trauma (22.4%) | Trauma (32.8%) | Trauma (31.3%) |
General illness (22.4%) | General illness (16.9%) | Behavioral/psychiatric (10.3%) | Behavioral/psychiatric (13.9%) |
Trauma (9.8%) | Seizure (16.0%) | Seizure (7.3%) | Pain non-chest/non-abdomen (9.2%) |
Prehospital care providers may be uncomfortable with pediatric patients. This can be due to limited knowledge and skills obtained during initial training, infrequent field experience, or a lack of continuing education. It can also be due to weight-based drug doses and equipment size variations in children. In addition, empathy in treating ill and injured children plays a large role. NAEMSP model pediatric protocols were developed so they would not have to be started from scratch in each system [4]. The particular protocol or algorithm chosen should be based on several factors including the structure of the system (e.g. one-tiered versus two-tiered; EMT versus paramedic), scope of practice decisions, transport times, continuing education requirements, skills retention, system quality improvement, and, of course, resources.
Evaluation of children
Evaluation is an area in which children are truly different. An accurate assessment of a pediatric patient is the key to proper field evaluation and treatment and, in turn, appropriate direct medical oversight. Evaluation should be tailored to each child in terms of age, size, and developmental level.
Pediatric Assessment Triangle
A useful learning tool that may be beneficial for providers is the Pediatric Assessment Triangle (PAT), which looks at Appearance, work of Breathing, and Circulation –a variation on the classic ABCs of primary assessment. This tool was developed by the Pediatric Education for Paramedics Task Force [5] and has been incorporated into the Pediatric Education for Prehospital Professionals (PEPP) program [6] and Advanced Pediatric Life Support (APLS) course [7].
The PAT allows the prehospital provider to develop a general impression of the child and determine if life support is needed urgently. The three parts of the triangle are done by watching and listening to the patient and do not require equipment. They can be accomplished from across the room and can be completed in 30–60 seconds.
Appearance
This is the most important component as it determines the severity of injury or illness. It consists of five characteristics, the TICLS mnemonic: Tone, Interactiveness, Consolability, Look/gaze, and Speech/cry. Assessment of tone includes: Is the child moving vigorously or is he limp? Interactiveness reflects how alert the child is: does she react to a voice or an object? Does the child reach for a toy or is he uninterested? Is the child consolable; can she be comforted? Look/gaze: Does the child look at the EMS provider or caregiver, or does the child have a blank expressionless face? Speech/cry: Is the cry or voice strong or weak? [6].
Work of Breathing
This portion of the tool can give the provider a quick indication of oxygenation and ventilation and can be done without a stethoscope. The characteristics to note include:
- abnormal airway sounds such as grunting, wheezing, or muffled phonation
- abnormal positioning such as the tripod position, sniffing position, or refusing to lie down
- presence and location of retractions presence of nasal flaring [6].
Circulation to the skin
This helps determine the adequacy of perfusion to vital organs, using three characteristics:
- pallor, which reflects inadequate blood flow
- mottling, which is due to vasoconstriction
- cyanosis, which is blue coloration of the skin and mucous membranes [6].
If there is an abnormality in one or more aspects of the triangle, this can help the provider decide how severely ill or injured the child is and the most likely physiological abnormality. For example, abnormal appearance and breathing point to a respiratory problem, whereas abnormal appearance and circulation point to a circulatory disorder. Abnormalities in all three areas point to a critically ill child who requires rapid scene interventions.
The next step in patient assessment is the ABCDEs.
- A – Airway: Assessment of the patient’s airway should include: Is it patent? Is the child maintaining his or her own airway or is assistance needed in the form of airway positioning: jaw thrust, chin-lift, oral airway, nasal airway, bag-mask, or endotracheal (ET) tube?
- B – Breathing: Respiratory rate varies with age and can be very difficult to obtain in a crying child. Children in respiratory distress will usually breathe fast but as they tire, the rate will decrease, which is an ominous sign. When one listens to the chest, are there any adventitious sounds (grunting, stridor, wheezing, rales, rhonchi) or no sounds (no air movement)? Depending on available equipment, the use of a pulse oximeter can help determine oxygen saturation and the need for supplemental oxygen and/or assisted ventilation.
- C – Circulation: Determining heart rate and strength of peripheral pulses (radial) can be accomplished together. Heart rate varies with age and can also increase with fever and anxiety, but a heart rate below the normal range is worrisome and can imply hypoxia or pending arrest. If peripheral pulses are weak, central pulses should be checked as a means of assessing circulation. Capillary refill, which should be less than 2 seconds, can be assessed with the evaluation of the temperature and color of the extremity. Cold, blue, pale, or mottled extremities indicate poor circulation and shock. Although obtaining a blood pressure is part of the vital signs, in children it is often inaccurate because of the wrong size cuff or a fighting child. A normal blood pressure in the face of some of the above abnormalities should not make a prehospital care provider comfortable. In fact, hypotension in a child is a late finding of shock.
- D – Disability: This is a brief assessment of level of consciousness (mental status). The key is a quick assessment done initially as general appearance, so this is a recheck. It is not necessary to memorize a pediatric Glasgow Coma Scale, as a rapid assessment uses the mnemonic AVPU: Awake, responsive to Voice, responsive to Pain, and Unresponsive.
- E – Exposure: Although parts of the ABCDEs require that parts of the body be exposed for a complete assessment, it is necessary to ensure that all of the child’s body has been examined to fully evaluate any abnormalities. At the same time, it is also important to prevent heat loss and hypothermia.
Vital signs
One of the most challenging aspects for prehospital care providers in the assessment of infants and children is that their vital signs change with age, so it is difficult to remember what is within a normal range. Having a table with appropriate vital signs for age is an easy way to solve this problem (Table 53.2).
Table 53.2 Vital signs

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Age | Weight (kg) | Respiration(min–max) | Heart rate(min–max) | Systolic blood pressure (min–max) |
Premie | 1–2 | 30–60 | 90–190 | 50–70 |
Newborn | 3–5 | 30–60 | 90–190 | 50–70 |
6 month | 7 | 24–40 | 85–180 | 65–106 |
1 year | 10 | 20–40 | 80–150 | 72–110 |
3 year | 15 | 20–30 | 80–140 | 78–114 |
6 year | 20 | 18–25 | 70–120 | 80–116 |
8 year | 25 | 18–25 | 70–110 | 84–122 |
12 year | 40 | 14–20 | 60–110 | 94–136 |
15 year | 50 | 12–20 | 55–100 | 100–142 |