Anatomy
Neck and Airway (A&P differ from adults, size and structure)
• Keep the nares clear with suctioning infants younger than 24 months.
▪ Nasal congestion is enough to cause respiratory distress in infants and toddlers.
• Tracheal cartilage in a child is softer than adult and more collapsible.
▪ Avoid Hyperextension of the neck- it may result in reverse hyper-flexion and kinking
of the trachea, may also displace the tongue posteriorly, creating an airway
obstruction.
• Keep the airway clear of all secretions.
▪ Even a small amount of particulate matter may result in an airway obstruction.
• Use care when you are inserting airway adjuncts.
▪ Jaw and soft tissue are delicate and susceptible to swelling.
▪ The child's airway can be maintained with correct positioning.
• Cuffed tubes improve the accuracy of capnography and improve tidal volume delivery.
▪ High cuff pressure can damage the airway mucosa, inflate the cuff with just enough
air until the air leak stops while listening over the trachea.
The Respiratory System
• Functional residual capacity is the volume of air remaining in the lungs following exhalation,
also referred as oxygen reserve.
• Infants use the diaphragm (belly breathers).
▪ Pressure on the abdomen of an infant or young child (seatbelts) can block the
movement of the diaphragm and cause respiratory compromise.
• Hypoxia is the most common cause of bradycardia and cardiovascular collapse in children.
▪ Use a BVM and use only enough pressure to achieve visible chest rise.
▪ Goal is to maintain a level greater than 94%.
▪ Any child with 60+ breaths/min should be a red flag.
Cardiovascular System
• An infant's pulse rate can be 200 beats/min or more if the body needs to compensate for
injury or illness.
▪ A child has a relatively large circulating blood volume, injured children can maintain
their blood pressure for longer periods, even though they are still in shock
(hypoperfusion).
• Suspect shock when an infant or child presents with tachycardia.
▪ Bradycardia indicated severe hypoxia and must be managed aggressively.
• Hypotension is an ominous sign and often indicates impending cardiopulmonary arrest.
• Constriction of blood flow to the body's periphery diminishes.
▪ Signs of vasoconstriction can include weak peripheral pulses, delayed capillary refill
younger than 6, and extremities that are cool and paler than baseline color or
mottles.
• Treatment for hypoxia aims to ensure adequate oxygenation and ventilation.
,The Heart
• The primary compensatory mechanism used to increase cardiac output in children is
increasing the pulse rate.
The Nervous System
• The pediatric brain requires a significant amount of blood, making even minor injuries
significant.
o This requirement increases the risk of hypoxia.
o Head injuries are greatly exacerbated by hypoxia and hypotension, causing
ongoing damage.
Spinal Column
• Specific mechanism of injury (MOIs) may cause compression fracture due to axial
loading.
• If confronted with a significant MOI, assume the child has a cervical spine injury and to
transport with SMR.
The Abdomen and Pelvis
• The appearance of abdominal distention in a healthy infant is due to the weak abdominal
wall muscle and the larger size of the solid organs.
• In younger children, the liver and spleen are lower in the abdomen and are less
protected by the rib cage.
▪ Injuries to these organs can result in significant blood loss because of their rich
blood supply.
▪ The lower ribs do not shield the kidneys from injury.
• The duodenum and pancreas are more likely to be damaged in handlebar injuries.
• Words of Wisdom-> even seemingly insignificant forces can cause serious internal
injuries in children. Multiple organ injuries (chest/abdomen) are common in pediatric
patients.
Musculoskeletal System
• Slipped Capital Femoral Epiphysis (SCFE)- a problem in the hip that affects the
epiphysis of the femur.
o There may be pain at the hip with normal flexion and rotation will be painful and
limited.
• Stabilize all sprains and strains and maintain a high level of suspicion for fractures.
o Use cold packs to reduce swelling.
The Chest and Lungs
• A child’s chest wall is thin, less musculature and less subcutaneous fat to protect the ribs
and organs.
• This increased laxity and flexibility can lead to significant intrathoracic injury despite
minimal external findings.
• Fragile lung tissues are more easily compressed during blunt trauma.
• Children are more vulnerable to pulmonary contusions, cardiac tamponade, and
diaphragmatic rupture.
,Integumentary System
• Infants and children have thinner and more elastic skin, a higher ratio of body surface
area (BSA) to weight and less subcutaneous (fatty) tissue.
o Increased risk of hypothermia.
o Increased severity of burns.
Metabolic Differences
• Maintain a high index of suspicion for hypoglycemia in any patient with lethargy,
seizures, or decreased activity.
• Children are more susceptible to hypothermia.
• Significant hypovolemia and electrolyte derangements can result from vomiting and
diarrhea.
o It is crucial to keep the child warm during transport and to take measures to
prevent loss of body heat.
o Cover the child's head (source of significant heat loss).
Pediatric Patient Assessment
Scene Size Up
• As you enter the scene, not the position in which the child is found.
• Observe the area for clues to the MOI or NOI.
• If the child is unable to communicate on a trauma scene because of age or is
unresponsive, assume the MOI was significant enough to cause head or neck injuries.
• SMR with a cervical collar should be performed if you suspect the MOI to be severe.
• Remember the need to pad under the pediatric patient's head and/or shoulders to
facilitate a neutral position for airway management.
• Note the presence of any pills, medicine bottles, alcohol, drug paraphernalia or
household chemicals that would suggest toxic exposure or possible ingestion by the
child.
Primary Survey
• The first step in the primary survey of any patient begins with your general impression of
how the patient looks.
• An assessment tool called Pediatric Assessment Triangle (PAT) helps providers form
a “from-the-doorway” general impression of pediatric patients.
• Three elements (child’s appearance, work of breathing, and circulation) collectively
paint an accurate clinical picture of the patient's cardiopulmonary status and level of
consciousness.
, • This quick assessment is completed before assessing ABCDEs and does not require
touching the patient.
• Helps establish urgency for treatment or transport.
Appearance
• Appearance reflects the adequacy of ventilation, oxygenation, brain perfusion, body
homeostasis and central nervous system function.
• TICLS Mnemonic (Tone, Interactiveness, Consolability, Look/Gaze and Speech/Cry.
• Unless a Child is unconscious or critically ill, take your time in assessing their general
appearance by observation before you begin the hands-on assessment and obtain vital
signs.
▪ Tone- Moving Vigorously or limp, listless or flaccid?
▪ Interactiveness- Child grasp or play with toys or Uninterested in playing?
▪ Consolability- Comforted or crying with consoling?
▪ Look/Gaze- fix gaze on face or no one's home stare?
▪ Speech/Cry- Strong/spontaneous cry or weak/muffled/hoarseness?
• In any event, a child with a grossly abnormal appearance is seriously ill and requires
immediate life support interventions and transport.
Work of Breathing
• A child's work of breathing is often a better assessment of their oxygenation and
ventilation status than auscultation of lung sounds or determining the child's respiratory
rate.
Neck and Airway (A&P differ from adults, size and structure)
• Keep the nares clear with suctioning infants younger than 24 months.
▪ Nasal congestion is enough to cause respiratory distress in infants and toddlers.
• Tracheal cartilage in a child is softer than adult and more collapsible.
▪ Avoid Hyperextension of the neck- it may result in reverse hyper-flexion and kinking
of the trachea, may also displace the tongue posteriorly, creating an airway
obstruction.
• Keep the airway clear of all secretions.
▪ Even a small amount of particulate matter may result in an airway obstruction.
• Use care when you are inserting airway adjuncts.
▪ Jaw and soft tissue are delicate and susceptible to swelling.
▪ The child's airway can be maintained with correct positioning.
• Cuffed tubes improve the accuracy of capnography and improve tidal volume delivery.
▪ High cuff pressure can damage the airway mucosa, inflate the cuff with just enough
air until the air leak stops while listening over the trachea.
The Respiratory System
• Functional residual capacity is the volume of air remaining in the lungs following exhalation,
also referred as oxygen reserve.
• Infants use the diaphragm (belly breathers).
▪ Pressure on the abdomen of an infant or young child (seatbelts) can block the
movement of the diaphragm and cause respiratory compromise.
• Hypoxia is the most common cause of bradycardia and cardiovascular collapse in children.
▪ Use a BVM and use only enough pressure to achieve visible chest rise.
▪ Goal is to maintain a level greater than 94%.
▪ Any child with 60+ breaths/min should be a red flag.
Cardiovascular System
• An infant's pulse rate can be 200 beats/min or more if the body needs to compensate for
injury or illness.
▪ A child has a relatively large circulating blood volume, injured children can maintain
their blood pressure for longer periods, even though they are still in shock
(hypoperfusion).
• Suspect shock when an infant or child presents with tachycardia.
▪ Bradycardia indicated severe hypoxia and must be managed aggressively.
• Hypotension is an ominous sign and often indicates impending cardiopulmonary arrest.
• Constriction of blood flow to the body's periphery diminishes.
▪ Signs of vasoconstriction can include weak peripheral pulses, delayed capillary refill
younger than 6, and extremities that are cool and paler than baseline color or
mottles.
• Treatment for hypoxia aims to ensure adequate oxygenation and ventilation.
,The Heart
• The primary compensatory mechanism used to increase cardiac output in children is
increasing the pulse rate.
The Nervous System
• The pediatric brain requires a significant amount of blood, making even minor injuries
significant.
o This requirement increases the risk of hypoxia.
o Head injuries are greatly exacerbated by hypoxia and hypotension, causing
ongoing damage.
Spinal Column
• Specific mechanism of injury (MOIs) may cause compression fracture due to axial
loading.
• If confronted with a significant MOI, assume the child has a cervical spine injury and to
transport with SMR.
The Abdomen and Pelvis
• The appearance of abdominal distention in a healthy infant is due to the weak abdominal
wall muscle and the larger size of the solid organs.
• In younger children, the liver and spleen are lower in the abdomen and are less
protected by the rib cage.
▪ Injuries to these organs can result in significant blood loss because of their rich
blood supply.
▪ The lower ribs do not shield the kidneys from injury.
• The duodenum and pancreas are more likely to be damaged in handlebar injuries.
• Words of Wisdom-> even seemingly insignificant forces can cause serious internal
injuries in children. Multiple organ injuries (chest/abdomen) are common in pediatric
patients.
Musculoskeletal System
• Slipped Capital Femoral Epiphysis (SCFE)- a problem in the hip that affects the
epiphysis of the femur.
o There may be pain at the hip with normal flexion and rotation will be painful and
limited.
• Stabilize all sprains and strains and maintain a high level of suspicion for fractures.
o Use cold packs to reduce swelling.
The Chest and Lungs
• A child’s chest wall is thin, less musculature and less subcutaneous fat to protect the ribs
and organs.
• This increased laxity and flexibility can lead to significant intrathoracic injury despite
minimal external findings.
• Fragile lung tissues are more easily compressed during blunt trauma.
• Children are more vulnerable to pulmonary contusions, cardiac tamponade, and
diaphragmatic rupture.
,Integumentary System
• Infants and children have thinner and more elastic skin, a higher ratio of body surface
area (BSA) to weight and less subcutaneous (fatty) tissue.
o Increased risk of hypothermia.
o Increased severity of burns.
Metabolic Differences
• Maintain a high index of suspicion for hypoglycemia in any patient with lethargy,
seizures, or decreased activity.
• Children are more susceptible to hypothermia.
• Significant hypovolemia and electrolyte derangements can result from vomiting and
diarrhea.
o It is crucial to keep the child warm during transport and to take measures to
prevent loss of body heat.
o Cover the child's head (source of significant heat loss).
Pediatric Patient Assessment
Scene Size Up
• As you enter the scene, not the position in which the child is found.
• Observe the area for clues to the MOI or NOI.
• If the child is unable to communicate on a trauma scene because of age or is
unresponsive, assume the MOI was significant enough to cause head or neck injuries.
• SMR with a cervical collar should be performed if you suspect the MOI to be severe.
• Remember the need to pad under the pediatric patient's head and/or shoulders to
facilitate a neutral position for airway management.
• Note the presence of any pills, medicine bottles, alcohol, drug paraphernalia or
household chemicals that would suggest toxic exposure or possible ingestion by the
child.
Primary Survey
• The first step in the primary survey of any patient begins with your general impression of
how the patient looks.
• An assessment tool called Pediatric Assessment Triangle (PAT) helps providers form
a “from-the-doorway” general impression of pediatric patients.
• Three elements (child’s appearance, work of breathing, and circulation) collectively
paint an accurate clinical picture of the patient's cardiopulmonary status and level of
consciousness.
, • This quick assessment is completed before assessing ABCDEs and does not require
touching the patient.
• Helps establish urgency for treatment or transport.
Appearance
• Appearance reflects the adequacy of ventilation, oxygenation, brain perfusion, body
homeostasis and central nervous system function.
• TICLS Mnemonic (Tone, Interactiveness, Consolability, Look/Gaze and Speech/Cry.
• Unless a Child is unconscious or critically ill, take your time in assessing their general
appearance by observation before you begin the hands-on assessment and obtain vital
signs.
▪ Tone- Moving Vigorously or limp, listless or flaccid?
▪ Interactiveness- Child grasp or play with toys or Uninterested in playing?
▪ Consolability- Comforted or crying with consoling?
▪ Look/Gaze- fix gaze on face or no one's home stare?
▪ Speech/Cry- Strong/spontaneous cry or weak/muffled/hoarseness?
• In any event, a child with a grossly abnormal appearance is seriously ill and requires
immediate life support interventions and transport.
Work of Breathing
• A child's work of breathing is often a better assessment of their oxygenation and
ventilation status than auscultation of lung sounds or determining the child's respiratory
rate.
