Good morning,

The month of September will be spent focusing on a few pediatric emergencies. It is important to know that before you can provide the best possible care and treatment for an ill or injured child, you have to know these two things. 

1. Children are not just “little adults” and therefore should not be treated as such.

2. You must be able to recognize a “sick” child from a “not sick” child within the first minute or so of contact.

A child’s anatomy differs in four significant ways from that of an adult:

• They have smaller airways

• Bigger heads

• Less blood volume

• Vulnerable internal organs

In terms of the airway, there are several reasons why a child’s airway is at greater risk during an airway compromise. The tongue takes up a proportionately large amount of space in the mouth making it easier to block the airway. The diameter of the trachea is smaller and not as rigid as that of an adult, and it will collapse easily if a child’s neck is flexed or hyperextended. 

Next, infants and children have relatively smaller blood volume when compared to that of an adult. A good rule of thumb is that there is approximately 70mL of blood for every 1 kg (~2lbs) of body weight. The internal organs of a child are not well protected. The soft bones and cartilage and lack of fat in the rib cage make internal organs susceptible to significant internal injuries. This is important to note because, with children, injury can be seen with a low-risk mechanism and without obvious signs of injury.

Lastly, a child’s head size is proportionally larger than an adult’s. They have a prominent occiput (the back of the head) and a relatively straight cervical spine. This causes the child’s head to flex forward (as in a sniffing position) when lying supine. It is important to place a “towel roll” or some other form of support underneath the shoulders.

Now let us discuss how we can recognize a “sick” child from a “not sick” child. A sick child is one who you believe is physiologically unstable based on observable clinical indicators. This means that you have observed an abnormality in appearance, work of breathing, or circulation to the skin. These patients require immediate treatment and transport to an appropriate facility. Do not make the mistake of failing to recognize and respond to the decompensating patient or the patient who has changed from “not sick” to “sick.” This is why frequent reassessments are key when transporting pediatric patients.

The “not sick” patient is one who you believe is physiologically stable. They have no significant abnormality in appearance, work of breathing, or circulation to the skin. They may not need immediate intervention but may require an evaluation at an appropriate facility. 

Next week, I will discuss the Pediatric Assessment Triangle, which includes appearance, work of breathing, and circulation to the skin. We make our assessments on these three things alone, in many cases, without touching the patient. These three clinical indicators reflect the overall status of a child’s cardiovascular, respiratory and neurologic systems. I will also discuss developmental considerations when evaluating children from infants to adolescents. 

Until then, please continue to do the great work that you are doing, and thank you for taking care of our children in the field.

Sincerely,

Regina A. Yaskey, MD, FAAP 

Pediatric Assessment Triangle - September  12, 2022

Good morning,

I hope you all had a nice week and holiday weekend. This week we will be discussing the Pediatric Assessment Triangle (PAT), a rapid assessment tool using only visual and auditory clues. It relies heavily on observational skills, requires no equipment, and takes seconds to perform. It enables you to articulate a formal impression of the child, establish the severity of the child’s presentation, category of pathophysiology, and determine the type and urgency of intervention needed. 

The PAT is made up of 3 components:

1. Appearance

2. Work of breathing

3. Circulation

Any observed abnormality within the arm of the triangle qualifies the entire component (arm) as abnormal. The combination of abnormal arms in the triangle determines the child’s category of illness and helps to identify the immediate intervention. 

Appearance is illustrated by the ‘TICLS’ mnemonic: Tone, Interactiveness, Consolability, Look or Gaze, and Speech or Cry. This arm is based on the child’s age and stage of development. 

Remember, abnormal position, abnormal breath sounds, retractions, or nasal flaring = Oxygen and ALS / PALS intervention!

Combining the three PAT components forms your general impression and overall evaluation of the child’s physiologic state. This distinguishes “sick” vs. “not sick” or “stable” vs. “not stable”.

There are six major assessment categories: stable, respiratory distress, respiratory failure, shock, central nervous system (CNS) dysfunction, metabolic disorder, and cardiopulmonary failure.PAT defines the urgency of treatment based on the assessment category, which in turn drives life-saving management (example, the delivery of oxygen, support of ventilation via BVM or intubation, establishing IV access and fluid resuscitation, emergency drug delivery, and the initiation of chest compressions). 

This concludes the Pediatric Assessment Triangle. Next week we will discuss developmental considerations when evaluating and caring for children and anaphylaxis. Until then, stay safe, work hard, and thank you so much for all your hard work and for taking care of our children in the field. Have a great week. 

Sincerely,

Regina A. Yaskey, MD, FAAP 

Developmental Considerations - October 19, 2022

Good morning,

Last week we discussed the Pediatric Assessment Triangle, an internationally accepted tool in pediatric life support for the initial emergency assessment of infants and children.

This week’s message will focus on identifying the developmental considerations when evaluating patients in different pediatric age groups. As a prehospital provider, you should be familiar and comfortable with the developmental considerations in each developmental stage, from infancy to adolescence. 

Infants: 1 – 12 months

Remember that infants are obligate nose breathers, meaning that obstruction of the nose will cause respiratory distress and increased work of breathing. They usually develop separation anxiety later in this period (around 6 months of age). When examining them, the goal is to provide sensory comfort and allow them to be examined with their caregiver holding them (or with whomever they feel comfortable). 

Toddler: 1 – 3 years

Most toddlers have stranger anxiety. You want to approach them slowly, sit down or squat next to them and use a quiet voice when talking. They are not good at localizing pain, no matter how advanced their verbal skills are. It is best to get the history from the parent. Use play and distracting objects when examining them and have their caregiver hold them. 

Preschool Age: 3 to 5 years

These children understand what is being done to them, so you can explain a procedure in simple terms. You can offer them a stuffed animal or toy to hold for the procedure and use games or distractions with them. Praise them for their good behavior but remember to set limits on their behaviors when they are unwilling to cooperate

School Age: 6 to 12 years

You can speak directly with these children, but be careful not to offer too much information, for they might get scared. Explain procedures immediately before carrying them out, and do not negotiate with them unless they have a choice. 

Adolescent: 12 to 15 years

In this age group, you want to explain what you are doing and why. Get the history from them if possible and show them respect. Remember to also respect their independence and address them directly. Allow the parents to be involved in the examination if the patient wishes. When asking questions about their sexual activity and illicit drug and alcohol use, please do so privately. 

Next week, we will discuss a difficult topic: child abuse and neglect. Remember that you are our eyes in the field. You need to be familiar with the signs of child abuse and neglect and know the differences between accidental and intentional injury patterns.

Thanks again for all your hard work. Have a great week and thank you for taking care of our children.

Sincerely,

Regina A. Yaskey, MD, FAAP 

Abuse - September 26, 2022

Good morning,

This week we will be discussing Child Abuse and Maltreatment. Rarely will you be dispatched on a call wherein a parent is calling because they have shaken, beaten up, or thrown their child into a wall. You will more likely be dispatched to a “new-onset seizure,” “an accidental fall”, or a “self-inflicted burn.” When arriving at calls like these, it is imperative to have a high index of suspicion for abuse. Remember that you are the first ones on the scene. It is vital that you have a basic understanding of the signs and symptoms of child abuse.

The overwhelming majority of pediatric patients transported to emergency departments are taken to a general or adult ED as opposed to a pediatric ED associated with a dedicated pediatric hospital. Barriers to recognizing child abuse most often stem from the discomfort of not being used to treating pediatric patients, being unprepared to distinguish between accidental and intentional injuries, and believing parental stories of injury occurrence It is in our nature to want to believe parents are telling us the truth. They may be upstanding members of our community. But we don’t know what happens behind closed doors, or what stressors may shape their world. Remember that abusers do not always fit a stereotype1. 

Child abuse is defined by the Child Abuse Prevention and Treatment Act as “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse, or exploitation; or an act or failure to act which presents an imminent risk of serious harm.” It includes physical injury, emotional injury, negligent treatment, maltreatment, and sexual exploitation of a child. Child neglect is also a form of child maltreatment because it endangers the child through the lack of physical or emotional needs from the parent or caregiver. Child neglect is the most common form, accounting for about 75% of reported cases. Neglect is followed by physical abuse (17.2%), sexual abuse (8.4%), psychological maltreatment (6.2%), and medical neglect (2.2%)2.

Physical abuse often has the most common visual sign of abuse: bruising, breaks, and burns (the three Bs). While bruising is a common manifestation, it is also the most common physical manifestation of childhood itself. The key to knowing the difference is in the history, location, and age of the victim3. 

The EMS provider holds a key position in assessing not only the child but their environment.

1. What are the living conditions of the child?

2. Do they appear to be in a safe or unsanitary environment?

3. Are the injuries consistent with the mechanism of injury?

4. Does the story being told change over time?

The following risk factors are commonly associated with child maltreatment4:

1. Children aged 3 or younger (most likely because they are not fully verbal)

2. Children living in a foster home

3. Children with chronic medical problems

4. Stepchildren

5. Children with behavioral or developmental problems

Bruises on the child who cannot yet walk are concerning. During your evaluation, look for unusual patterns and locations of bruises. Ambulatory children will normally have bruises over extensor surfaces, such as their elbows, knees, and forehead. Bruises that may cause you to suspect abuse are often discovered in locations typically covered up by clothing or are in strange places other than where children would land if they fell. These include the back, upper arms, upper legs, abdomen, buttocks, and the pinna of the ear. Seizures, coma, and even death may occur from these injuries.

Be suspicious of parents who do not want their child to go to any hospital or a hospital where the child has been seen before. You should also be wary of incompatible or changing explanations of the child’s injury or a history that does not account for the injury. Ask the parents to describe in detail how the injury occurred. Watch their reaction to your questions. Observe the environment or the mechanism of injury where the child was hurt. The parent’s story can later be compared to that of the hospital staff. Suspicious situations include:

1. Delay in seeking medical treatment

2. Suggestion by the child that someone hurt them intentionally

3. Anger, hostility, or lack of appropriate concern by the parent

4. Immaturity, quick temper, and rigid behavioral standards demonstrated by a parent

Never voice your suspicions to the parents or accuse them of anything. If the parents do not want the child transported, insist that the child’s injury cannot be evaluated in the field. Remember, you cannot legally take a child against a parent’s wishes. If they resist, call Medical Command for assistance.

Remember that child maltreatment/abuse occurs regardless of ethnicity, culture, religion, or financial or social status. Child abuse is seen in all socioeconomic classes.

The final step in a child abuse case is reporting to Child Protective Services (CPS). Every state in the United States has laws defining mandated reporters, and EMS providers are mandatory reporters in all states. Many of you have good relationships with the medical staff at the facilities where you transport patients. If the medical staff makes a referral to CPS, then you will not have to, although it is always best practice to do so. Reluctance by the hospital team should not deter your reporting if you are not in agreement. It is always best to advocate for the safety and well-being of a child who may be unable or too fearful to advocate for themselves. If you feel child maltreatment has occurred, you should report to CPS regardless of the opinion of the hospital staff. Child abuse cases are sometimes not easy to diagnose and may slip through the cracks. The more we educate ourselves on abuse and neglect, the more empowered we will become to advocate for these children. Dealing with children who have suffered abuse or neglect strengthens our ability to advocate for them. It is a difficult topic to cover, but one that we should be familiar with nonetheless.

Thank you for having me this month. Thank you for taking care of our children in the field. Keep up the great work and have a happy Fall season. 

Sincerely,

Regina A. Yaskey, MD, FAAP