Pediatric Assessment Triangle
Work of breathing
Circulation to the skin
Begin your assessment with the ___ and move toward the ___ in children under 6.
Respiratory rate, HR, BP, and temperature of neonate
30 to 60
90 to 160
67/35 to 84/53
98 to 100
Respiratory rate, HR, BP, and temperature of infant
30 to 53
90 to 150
72/37 to 104/56
96.8 to 99.6
Respiratory rate, HR, BP, and temperature of toddler
22 to 37
80 to 120
86/42 to 106/63
96.8 to 99.6
Respiratory rate, HR, and BP of preschool age
20 to 28
65 to 100
89/46 to 112/72
Respiratory rate, HR, and BP of school age
18 to 25
58 to 90
97/57 to 120/80
Respiratory rate, HR, and BP of adolescent
12 to 20
50 to 90
110/64 to 131/83
Even though the tidal volume in children is similar to adults, children have smaller oxygen reserves due to “
Metabolic oxygen demand is doubled
Functional residual capacity is smaller
Keep the nares clear in infants younger than ____.
Signs of vasoconstriction
Weak peripheral pulses in extremities
Delayed capillary refill
Pale, cold extremities
Pediatric differences in skin -thinner more elasticity, increased surface area, and decrease subcutaneous tissue - contributes to an increase in :
Severity of burns
Injury following temperature extremes
Tone Interactiveness Consolability Look or gaze Speech or cry
What does the appearance aspect of PAT reflects?
Adequacy of ventilation Oxygenation Brain perfusion Body homeostasis CNS function
Signs of work of breathing
Tachypnea Abnormal airway noises Retractions of intercostal muscles or sternum Abnormal posturing Head bobbing Nasal flaring
Three characteristics when assessing circulation :
What is mottling caused by?
Constriction of peripheral blood vessels
What are the components of assessing breathing?
Auscultate breath sounds
What are the components of assessing circulation?
Control active bleeding HR and quality Skin Capillary refill BP
In infants, palpate the _____ pulse or _____ pulse.
In children older than 1 year, palpate the _____ pulse.
Weak or absent peripheral pulses are indications of?
Weak central pulses indicate?
Absence of central pulse indicates?
Immediate need for CPR
Indications of rapid transport
Significant MOI Hx compatible w/ serious illness Physical abnormality Potentially serious anatomic abnormality Significant pain AMS s/s shock
When should a pediatric patient be placed in a cart seat during transport?
Weighing less than 40 lbs and do not require spinal immobilization
Capillary refill should be noted in children younger than ___ years.
To obtain an accurate reading of a pediatric patient’s BP, use a cuff that covers _____ of the upper arm.
Formula for calculating BP in children aged 1 to 10.
(Age [in years] x 2) / 70
<20 kg : 1.25 mg
>20 kg : 2.5 mg
Over 20 minutes. May repeat once within 20 minutes.
> 1 y/o : 0/5-1 g/kg via slow IV/IO push.
Repeat as necessary.
Neonates and infants : 200 - 500 mg/kg slow IV push. Repeated as necessary. Mx concentration of 12.5%
2.5 - 5.9 mL/kg
Administrated w/ infusion.
Anaphylaxis and asthma : 0.01 mg/kg of 1 mg/mL solution SQ/IM.
Max dose of 0.3 mg.
Can repeat every 5 minutes.
<20 kg or 5 y/o : 0.5 mg IM/IN
>20 kg : 1 mg IM/IN
< 20 kg or 5 y/o : 0.1 mg/kg IV/IO/IM
>20 kg or 5 y/o : 2.0 mg
Repeat every 2 minutes PRN.
Max dose of 2 mg.
0.5-1 g/kg PO
Signs of respiratory distress
Pallor or mottled color Irritability, anxiety, restlessness Increased respiratory rate Retractions Abdominal breathing Nasal flaring Inspiratory stridor Grunting Mild tachycardia
Signs of impending respiratory failure
AMS Central cyanosis, pallor Tachypnea to bradypnea to apnea Severe retractions Accessory muscle use Nasal flaring Grunting Paradoxical Abdominal motion Tripod position Tachycardia to bradycardia
3 causes of airqay obstruction in children
When should you consider an infection as a possible cause of airway obstruction?
Patient has congestion, fever, drooling, and cold sxs.
Signs of severe airway obstruction
Ineffective cough Inability to speak or cry Increasing respiratory difficulty w/ stridor Cyanosis LOC
If an infant is conscious with a complete airway obstruction, perform:
5 back blows followed by 5 chest thrusts
If a child older than 1 year is conscious with a complete airway obstruction, perform :
Management of anaphylaxis
Fluid resuscitation for shock
Bronchodilators for wheezing
s/s of croup
Cold symptoms Low-grade fever Barky cough Stridor Difficulty breathing
Management for croup
Position of comfort
Nebulize epinephrine if stridor at rest, mod to severe resp distress, poor air exchange, hypoxia or AMS
s/s of epiglottitis
Looks sick Anxious Sniffing position Drooling Increased work of breathing Pallor or cyanosis High fever Sore throat
Management of epiglottitis
Position of comfort
Supplemental oxygen if tolerated
BVM and suction ready
Where is the best place to auscultate breath sounds in a pediatric patient?
Level of armpit
URI Allergies Changes in environmental temperature Smoke Physical exertion Emotional stress
What is the pathophysiology of an acute asthma attack?
The body starts with the immune system responding to the trigger releasing histamines. As the attack progresses, mucous membranes in the bronchiolar walls swell and mucous plugging in the bronchiolar lumen restrict expiratory airflow. Pulmonary gas exchanged in impaired and the child becomes hypoxemic.
s/s of acute asthma attack
Preferential position Prolonged expiratory phase Wheezing Tachycardia Tachypnea Agitation
What age group is pneumonia commonly seen in pediatric patients?
Infants, toddlers, and preschoolers
s/s of pneumonia
Rapid breathing Grunting Wheezing Nasal flaring Tachypnea Crackling Hypothermia Fever
What is bronchiolitis?
Bronchioles become inflamed, swell, and fill with mucus.
Type of cough described as whooping during inspiratory phase
Contraindications for NPA
The _____ naris is commonly larger than the ___ naris.
When should you use a BVM?
Respirations less than 12 breaths or more than 60 breaths, AMS, inadequate tidal volume.
Signs of shock in children
Poor capillary refill
Common causes of shock in pediatric patients
Greater than ____ blood volume loss significantly increases the risk of shock in children.
Low blood pressure is a sign of _____ shock.
Management of shock in pediatric patients
Ensure patent airway Prepare for ventilation Control bleeding Give supplemental oxygen Position of comfort Keep warm IV access Administer nl saline or 20 mL/kg boluses of lactacted ringer solution to maintain perfusion Immediate transport Call ALS PRN
Signs in anaphylactic shock
Hypoperfusion Stridor and/or wheezing Increased work of breathing Restlessness, agitation, impending doom Hives
Management for anaphylactic shock
IV or IO access
Administer 20 mL/kg of isotonic crystalloid solution to maintain perfusion
Call ALS early if advanced airway is needed
Explain why butterfly catheters are associated with a higher rate of infiltration?
A stainless steel needs lies within the vein rather than a Teflon catheter or over-the-needle catheter.
When should you attempt IO access?
3 unsuccessful attempts with IV or 90 seconds in a critically ill or injure patient
What can occur if too much fluid is administered in pediatric patients?
Acute left-sided heart failure and pulmonary edema
Formula for kg if weight of pediatric patient is unknown.
(age [in years] x 2) + 8 = weight in kg
Most common causes of AMS in children :
drug or ETOH ingestion
How do nonverbal infants demonstrate responsiveness?
Follow a person’s face or object (tracking)
Babbling and cooing
Common causes of seizures in children :
Child abuse Electrolyte imbalance Fever Hypoglycemia Infection Ingestion Hypoxia Poisoning Seizure disorder Recreational drug use Head trauma Idiopathic
Signs of seizures in infants can be :
Management of seizures
Consider left recumbent position if actively vomiting and suction is inadequate
Provide 100% oxygen via NRB or blow-by
Occurs first day of febrile illness
Generalized tonic-clonic seizure
Lasts less than 15 minutes
Management for febrile seizures
Maintain airway Begin cooling with tepid water IV or IO access Blood sugar reading Prompt transport
s/s of meningitis
s/s of meningitis in infants
Increasing irritability especially when handles
Bulging fontanelle w/o crying
Management of meningitis
IV access and administer IV fluids if vital signs are unstable.
Questions you should ask to determine fluid loss.
How many wet diapers has your child had today?
Is your child tolerating liquids and are they able to keep them down?
How many times has your child had diarrhea and for how long?
Are tears present when your child cries?
Common sources of poisonings in children :
ETOH ASA and APAP Household cleaning products Houseplants Iron Rx medications Illicit drugs Vitamins
Vital signs and sxs of severe dehydration
HR : >160 Activity : variable, weak Urine output : none Skin : cool, clammy, poor turgor, delayed cap refill Mouth : dry mucous membranes Eye : sunken eyes Anterior fontanelle : extremely sunken Consciousness : altered BP : normal to low
What is the most common cause of dehydration in children?
Vomiting and diarrhea
Common causes of fever in peds.
Infection Status epilepticus Cancer ASA ingestion Arthritis and systemic lupus erythematosus High environmental temperatures
Signs of hypoglycemia
Hunger Malaise Tachycardia Tachypnea Diaphoresis Tremors
Management for hypoglycemia
Administer 100% oxygen
Oral glucose or IV glucose
Unable to obtain IV/IO access contact medical control to administer 1 mg of glucagon IM.
How to dilute D50 to D25 for pediatric use?
D50 25 g of dectrose in 50 mL of water. Push out 25 mL of D50 and draw 25 mL of normal saline. (1:1 ration) 12.5 g in 50 mL
How to dilute D50 to D10?
Draw 4 mL of D50 into 20 mL syringe. Draw 16 mL of NS with same syringe. (1:4 ratio) 2g in 20 mL
How to dilute D25 to D10?
Use prepared D25 in 50 mL. Push out 40 mL of D25 and draw 40 mL of NS resulting in 5g of 50 mL.
Management of hyperglycemia
Administer 100% oxygen
Assist w/ ventilations PRN
Monitor vital signs
Administer 20 mL/kg bolus if isotonic crystalloid solution to maintain adequate perfusion
Call ALS if respiratory status deteriorates
Management of drowning
Assess and manage ABCs
Administer 100% oxygen NRB or BVM
Apply c-collar and place on backboard if trauma is suspected
Perform CPR if unresponsive and in cardiopulmonary arrest
Suspect a serious ____ in any child who experiences nausea and vomiting after a traumatic event.
At what age is it no longer required for you to pad underneath a child’s torso to create a neutral position?
Age 8 to 10
When can the patient be left in their car seat?
Vital signs are stable
Car seat is visibly undamaged
Why are burns to children considered more serious than adults?
Children have more surface area relative to their total body mass which means greater fluid and heat loss.
Describe a minor severe of burn
Partial-thickness involving less than 10% of body surface
Describe a moderately severe burn.
Partial-thickness involving 10% to 20% of body surface
Describe a critically severe burn.
Any partial-thickness involving more than 20% of body surface.
Any burn involving hands, feet, face, airway, or genitalia.
CHILD ABUSE mnemonic
C : consistency of the injury H : history inconsistent w/ injury I : inappropriate parental concerns L : lack of supervision D : delay in care A : parent or caregiver affect B : bruising of varying degrees U : Unusual injury patterns S : suspicious circumstances E : environmental clues
Locations of bruises that are suspicious
Back, buttocks, ears, or face
What type and location of fractures should you be suspicious of?
Humerus or femur fx
Necessities of life that should be provided by caregiver or parent.
Food, water, clothing, shelter, personal hygiene, medicine, comfort, and personal safety
Three tasks first responders are responsible for at the scene of a suspected SIDS.
Assessment of the scene
Assessment and management of the patient
Communication and support of the family
When inspecting the environment of a suspected SIDS scene, what should you concentrate on?
Signs of illness, including medications, humidifies, thermometers General condition of the house Signs of poor hygiene Family interaction Site where the child was discovered
Signs of SIDS
Pale or blue
Brief Resolved Unexplained Event
Distinct change in muscle tone
Choking or gagging