APPROACH TO THE EMERGENCY EVALUATION OF A CHILD

 The first response to a pediatric emergency of any cause is a systematic, rapid

general assessment of the scene and the child to identify immediate threats to
the child, care providers, or others.
 If an emergency is identified, the emergency response system (emergency
medical services [EMS]) should be activated immediately.
 Care providers should then proceed through primary, secondary, and tertiary
assessments as allowed by the child’s condition, safety of the scene, and
resources available.
 This standardized approach provides organization to what might otherwise be a
confusing or chaotic situation and reinforces an organized thought process for
care providers.
 If, at any point in these assessments, the caregiver identifies a life-threatening
problem, the assessment is halted and lifesaving interventions are begun.
 Further assessment and intervention should be delayed until other caregivers
arrive or the condition is successfully treated.

General Assessment

 Upon arrival at the scene of a compromised child, a caregiver’s first task is a

quick survey of the scene itself.
 Is the rescuer or child in imminent danger because of circumstances at the
scene (fire, highvoltage electricity)?
 If so, can the child be safely extricated to a safe location for assessment and
treatment?
 Can the child be safely moved with the appropriate precautions (i.e., cervical
spine protection), if indicated?
 A rescuer is expected to proceed only if these safety conditions have been
met.
 Once the caregiver and patient’s safety has been ensured, the caregiver
performs a rapid visual survey of the child, assessing the child’s general
appearance and cardiopulmonary function.
 This action should be very quick (only a few seconds) and should include
assessment of (1) general appearance (determining color, tone, alertness, and
responsiveness); (2) adequacy of breathing (distinguishing between normal,
comfortable respirations and respiratory distress or apnea); and (3) adequacy of
circulation (identifying cyanosis, pallor, or mottling).
 A child found unresponsive from an unwitnessed collapse should be
approached with a gentle touch and the verbal question, “Are you OK?” If
there is no response, the caregiver should immediately shout for help and send
someone to both activate the emergency response system (EMS) and locate an
automated external defibrillator (AED).
 The provider should then determine whether the child is breathing and, if not,
provide 2 rescue breaths as described later under “Recognition and Treatment
of Respiratory Distress and Failure.”
  If the child is adequately breathing, then the circulation is quickly assessed.
 Any child with a heart rate below 60 beats/ min or without a pulse requires
immediate CPR, as described under “Recognition and Management of Cardiac
Arrest.” If the caregiver witnesses the sudden collapse of a child, the caregiver
should have a higher suspicion for a sudden cardiac event. In this case, rapid
deployment of an AED is of paramount importance. The provider should very
briefly delay care of the child to activate EMS and locate the nearest AED.

Primary Assessment

 Once the emergency response system has been activated and the child is
determined not to need CPR, the caregiver should proceed with a primary
assessment that includes a brief, hands-on assessment of cardiopulmonary and
neurologic function and stability.
 This assessment includes a limited physical exam, evaluation of vital signs,
and measurement of pulse oximetry if possible.
 Again, a standardized approach is best.
 The American Heart Association, in its Pediatric Advanced Life Support
(PALS) curriculum, supports the structured format of Airway, Breathing,
Circulation, Disability, Exposure (ABCDE).
 The goal of the primary assessment is to obtain a focused, systems-based
assessment of the child’s injuries or abnormalities, so that resuscitative efforts
can be directed to these areas; if the caregiver identifies a life-threatening
abnormality, further evaluation is postponed until appropriate corrective action
has been taken.
 The exam and vital sign data can be interpreted only if the caregiver has a
thorough understanding of normal values.
 In pediatrics, normal respiratory rate, heart rate, and blood pressure have age-
specific norms (Table 67-1). These ranges can be difficult to remember,
especially if used infrequently. However, several standard principals apply: (1)
no child’s respiratory rate should be >60 breaths/min for a sustained period; (2)
normal heart rate is roughly 2-3 times normal respiratory rate for age; and (3)
a simple guide for pediatric blood pressure is that the lower limit of systolic
blood pressure should be ≥60 mm Hg for neonates; ≥70 mm Hg for 1 mo-1
yr olds; ≥70 mm Hg + (2 × age) for 1-10 yr olds; and ≥90 mm Hg for any
child older than 10 yr.

Airway and Breathing

 The most common precipitating event for cardiac instability in infants and
children is respiratory insufficiency.
 Therefore, rapid assessment of respiratory failure and immediate restoration of
adequate ventilation and oxygenation remain the first priority in the
resuscitation of a child.
  Using a systematic approach, the caregiver should first assess whether the
child’s airway is patent and maintainable.
 A healthy, patent airway is open and unobstructed, allowing normal respiration
without noise or effort.
 A maintainable airway is one that is either already patent or can be made
patent with a simple maneuver.
 To assess airway patency, the provider should look for breathing movements in
the child’s chest and abdomen, listen for breath sounds, and feel the movement
of air at the child’s mouth and nose.
 Abnormal breathing sounds (i.e., snoring or stridor), increased work of
breathing, and apnea are all findings potentially consistent with airway
obstruction.
 If there is evidence of airway obstruction, then maneuvers to relieve the
obstruction should be instituted before the caregiver proceeds to evaluate the
child’s breathing.
 Assessment of breathing includes evaluation of the child’s respiratory rate,
respiratory effort, abnormal sounds, and pulse oximetry.
 Normal breathing appears comfortable, is quiet, and occurs at an
ageappropriate rate.
 Abnormal respiratory rates include apnea and rates that are either too slow
(bradypnea) or too fast (tachypnea).
 Bradypnea and irregular respiratory patterns require urgent attention, as they
are often signs of impending respiratory failure and apnea.
 Signs of increased respiratory effort include nasal flaring, grunting, chest or
neck muscle retractions, head bobbing, and “seesaw” respirations.
 Hemoglobin oxygen desaturation, as measured by pulse oximetry, often
accompanies parenchymal lung disease apnea or airway obstruction.
 However, providers should keep in mind that adequate perfusion is required to
produce a reliable oxygen saturation measurement.
 A child with low oxygen saturation is a child in distress.
 Central cyanosis is a sign of severe hypoxia and indicates an emergent need
for oxygen supplementation and respiratory support.

Circulation

 Cardiovascular function is assessed by evaluation of skin color and

temperature, heart rate, heart rhythm, pulses, capillary refill time, and blood
pressure.
 In nonhospital settings, much of the important information can be obtained
without measuring the blood pressure; lack of blood pressure data should not
prevent the provider for determining adequacy of circulation or implementing a
lifesaving response.
 Mottling, pallor, delayed capillary refill, cyanosis, poor pulses, and cool
extremities are all signs of diminished perfusion and compromised cardiac
output.
 Tachycardia is the earliest and most reliable sign of shock, but is itself fairly
nonspecific and should be correlated with other components of the exam, such
as weakness, threadiness, and absence of pulses.
  An age-specific approach to pulse assessment will yield best results.

Disability

 In the setting of a pediatric emergency, disability refers to a child’s neurologic

function in terms of the level of consciousness and cortical function.
 Standard evaluation of a child’s neurologic condition can be done quickly with
an assessment of pupillary response to light (if one is available) and use of
either of the standard scores used in pediatrics: the Alert, Verbal, Pain,
Unresponsive (AVPU) Pediatric Response Scale and the Glasgow Coma Scale
(GCS).
 The causes of decreased level of consciousness in children are numerous and
include conditions as diverse as respiratory failure with hypoxia or hypercarbia,
hypoglycemia, poisonings or drug overdose, trauma, seizures, infection, and
shock.
 Most commonly, an ill or injured child has an altered level of consciousness
because of respiratory compromise, circulatory compromise, or both.
 Any child with a depressed level of consciousness should be immediately
assessed for abnormalities in cardiorespiratory status.

Alert, Verbal, Pain, Unresponsive Pediatric Response Scale.

 The AVPU scoring system is used to determine both a child’s level of

consciousness and cerebral cortex function.
 Unlike the GCS (see later), the AVPU scale is not developmentally dependent
—a child does not have to understand spoken language or follow commands,
merely respond to a stimulus. The child is scored according to the amount of
stimulus required to get a response, from alert (no stimulus, the child is
already awake and interactive) to unresponsive (child does not respond to any
stimulus).

The Glasgow Coma Scale

 Although the GCS has not been validated as a prognostic scoring system for
infants and young children as it has been in adults, it is commonly used in
the assessment of pediatric patients with an altered level of consciousness.
 The GCS is the most widely used method of evaluating a child’s neurologic
function and has 3 components.
 Individual scores for eye opening, verbal response, and motor response are
added together, with a maximum of 15 points.
 Patients with a GCS score ≤8 require aggressive management, including
stabilization of the airway and breathing with endotracheal intubation and
mechanical ventilation, respectively, and, if indicated, placement of an
intracranial pressure monitoring device.
Exposure

 Exposure is the final component of the pediatric primary assessment.

 This component of the exam is reached only after the child’s airway,
breathing, and circulation have been assessed and determined to be stable or
have been stabilized through simple interventions.
 In this setting, exposure stands for the dual responsibility of the provider to
both expose the child to assess for previously unidentified injures and consider
prolonged exposure in a cold environment as a possible cause of hypothermia
and cardiopulmonary instability.
 The provider should undress the child (as is feasible and reasonable) to
perform a focused physical exam, assessing for burns, bruising, bleeding, joint
laxity, and fractures.
 If possible, the provider should assess the child’s temperature. All maneuvers
should be performed with careful maintenance of cervical spine precautions.

Secondary Assessment

 For care providers in community or outpatient settings, transfer of care of a

child to emergency or hospital personnel may occur before a full secondary
assessment is possible.
 However, before the child is removed from the scene and separated from
witnesses or family, a brief history should be obtained for medical providers at
the accepting facility.
 The components of a secondary assessment include a focused history and
focused physical exam.
 The history should be targeted to information that could explain
cardiorespiratory or neurologic dysfunction and should take the form of a
SAMPLE history (Signs/symptoms, Allergies, Medications, Past medical history,
timing of Last meal, and Events leading to this situation).
 Medical personnel not engaged in resuscitative efforts can be dispatched to
elicit history from witnesses or relatives.
 The physical exam during the secondary assessment is a thorough head-to-toe
exam, although the severity of the child’s illness or injury could necessitate
curtailing portions of the exam or postponing nonessential elements until a
later time.

Tertiary Assessment

 The tertiary assessment occurs in a hospital setting, where ancillary laboratory

and radiographic assessments contribute to a thorough understanding of the
child’s condition.
 A basic blood chemistry profile, complete blood count, liver function tests,
coagulation studies, and arterial blood gas analyses give fairly broad (but
somewhat nonspecific) estimates of renal function, acid–base balance,
cardiorespiratory function, and presence or absence of shock.
 Chest radiographs can be useful to evaluate both the heart and lungs, although
more detailed estimates of heart function and cardiac output can be made with
echocardiography.
 Arterial and central venous catheters can be placed to monitor arterial and
central venous pressure