Lecture 3: Pediatric Considerations
Objectives
On completion of this module, the
EMA/Paramedic will be able to:
 describe the components of the pediatric acuity
assessment
 perform an assessment on a pediatric patient
and assign an appropriate acuity level using the
CTAS acuity scale
 discuss the considerations required to assign an
acuity level to the pediatric patient
Use of EMS by Pediatric Patients
 fewer
than 10% of requests for medical
services are for children
 caregivers often choose to transport their
critically or seriously ill or injured child to
an emergency department by private
vehicle rather than waiting for emergency
medical services to respond.
– Reference: Institute of Medicine, Division of Health Services,
National Research Council
Unique Attributes of the Pediatric
Patient
are not small adults, (it’s the
other way around)
 children
 differences
include size, thought
processes, physical and emotional
maturity and social development.
Pediatric Considerations
 children
are less likely to have life
threatening conditions
 symptoms of life threatening problems
may be subtle and progress rapidly,and
 frequently involve the respiratory
system or central nervous system
Pediatric Considerations
 accurate
assessment is critical due to
the potential for rapid deterioration
 the child’s diagnosis is not as important
as recognition of the potential for rapid
deterioration based on history and
physical findings
Pediatric Considerations
•a physiologic assessment of the child will assist
in assigning the acuity level
•patients with abnormal vital signs- heart rate or
respiratory rate, are level 1 or level 2
Components of the Pediatric
Assessment
•
•
•
pediatric assessment triangle
pediatric history (subjective data)
physical assessment (objective data)
Pediatric Assessment Triangle
Appearance
Work Of
Breathing
Circulation
Pediatric Assessment Triangle

General appearance
– activity level
– level of consciousness

Work of breathing
– respiratory rate
– respiratory effort

Circulation
– heart rate
– perfusion
The “Key Look”: Using sight,
hearing, smell, and touch
 non
verbal cues: facial grimaces, fear, cyanosis
 listen for a cough, hoarseness, or labored breathing
 touch the patient, assess heart rate, skin
temperature and moisture, capillary refill
 assess for odors such as ketones, alcohol or
infection
Pediatric Physical Assessment:
•
•
•
may be limited if patient requires rapid access to
care/interventions (Level 1 & Level 2)
all pediatric patients must have their general
appearance, respiratory rate, effort and
perfusion evaluated initially
Note:
age/developmentally appropriate behavior
and social interactions
indications of child maltreatment (does the
story make sense?)
Pain Assessment in Children
 tachycardia,
pallor, sweating and other
physiological signs are also used to evaluate pain
 pain
scales are less helpful (or reliable) at the
extremes of age
 the parents can give an indication of the severity of
pain
 pain perception may be influenced by age, past
experience and cultural differences
Pediatric Vital Signs
 abnormal
vital signs are often a late
finding
 tachycardia is an early indication of
hypotension or hypovolemia
 abnormal VS
 level
1 patients have VS- HR or RR > 2 SD
 level 2 patients have VS- HR or RR > 1 SD
Pediatric Vital Signs
______________________________________________________________________________
Age
Respiratory Rate ( RR)
Heart Rate ( HR )
Normal
+/-1SD +/-2SD
Normal
+/-1SD
Range (NR)
Range(NR)
Birth - 3 months
months - 6 months
6 months -1 year
1 year - 3 years
6 years
10 years
30 - 60
30 - 60
25 - 45
20 - 30
16 - 24
14 - 20
20 – 70
20 – 70
17 – 55
15 – 35
12 – 28
10 – 24
10 – 80
10 - 80
10 - 60
10 - 40
8 - 32
8 - 26
90 –180
80 –160
80 –140
75 –130
70 –110
60 – 90
65 – 205
63 –180
60 –160
58 –145
55 –125
45 –105
______________________________________________________________________________
+/-2SD
40 - 230
40 - 210
40 -180
40 -165
40 -140
30 -120
CTAS Level 1
Resuscitation
CTAS Level I: Explanation
• require aggressive treatment
• pre and post arrest
• unable to speak due to respiratory distress, cyanosis
• lethargic/confused
• tachycardia/bradycardia
• O2 saturation < 90%
•VS HR or RR > 2 SD
CTAS Level 1: Physiologic
Assessment
• unresponsive
• severe respiratory distress/inadequate
breathing
• cardiac arrest/shock/cyanosis
• respiratory rate greater/less than 2
standard deviations from normal range
• heart rate greater/less than 2 standard
deviations from normal range
CTAS Level 1: Usual Presentations
 Severe
respiratory distress
– airway compromise
– near death asthma
– anaphylaxis
– congestive heart failure
– pneumothorax
CTAS Level 1: Usual Presentations
 Major
trauma
- head injury with GCS < 10
- severe burns (> 25% TBS or airway
problem)
- spinal injury with neurologic deficit
CTAS Level 1: Usual Presentations
Major Trauma:
–Chest/abdominal injury with any of:
– i) hypotension and tachycardia, usually
with severe pain (pain scale 8-10),
–ii) respiratory distress with abnormal rate,
volume, or decreased air entry,
–iii) altered mental state suggesting
hypoxemia or hypoperfusion.
CTAS Level 1: Usual Presentations
 Shock
states:
– shock/hypotension/ tachycardia
– anaphylaxis
– septic
CTAS Level 1: Usual Presentations
 Unconscious/unresponsiveness
– active seizures
– intoxications/overdoses
– hypoglycemia
– metabolic disturbances
-
NB: All patients with altered mental state
must have a rapid blood sugar screen test.
CTAS Level 2
Emergent
CTAS Level 2: Explanation



unstable child with moderate to severe
respiratory distress with potential to deteriorate
altered level of consciousness
abnormal vital signs: VS -HR or RR > 1
SD<2 standard deviations


need for rapid treatment on arrival
controlled acts may have been applied in the
prehospital setting (ALS)
CTAS Level 2: Physiologic
Assessment
• altered consciousness
• altered mental status: lethargic, drowsy,
agitated, inconsolable
• moderate respiratory distress/marked
stridor
• capillary refill greater than 4 seconds
CTAS Level 2: Usual Presentations
 Head
injury
– GCS < 13
– severe headache, loss of consciousness
>5 minutes, confusion, neck symptoms and
nausea or vomiting
CTAS Level 2: Usual Presentations
 Overdose
– intentional and unintentional
CTAS Level 2: Usual Presentations
 Fever
- age < 3 months
- temperature > 38.0 0 C
- immunocompromised
- chemotherapy
- chronic illness
CTAS Level 2: Usual Presentations
 Vomiting
and/or diarrhea
- signs of moderate to severe dehydration
- altered level of consciousness
- capillary refill > 2 seconds
- hypotension
Moderate to Severe Dehydration
 decreased
capillary refill,
 tachycardia,
 decreased urine production,
 decreased skin turgor,
 dry oral mucosa,
 sunken fontanelle,
 and lethargy
CTAS Level 2: Usual Presentations
 Neonates
– less than 7 days of age
CTAS Level 2: Usual Presentations
 Child
Abuse/neglect
- afebrile with altered level of consciousness
- history of ongoing risk
- unexplained trauma
CTAS Level 2: Usual Presentations
 Serious
infections
- purpuric skin rashes ( non blanching spots)
- history of fever or chills with rigors
- temperature instability in neonates
- infants less than 3 months temperature < 36 or >38
- immunosuppressed and asplenic children
- infants more than 3 months with fever and a toxic
appearance
Case Presentations
A
15 year-old male was hit by a car and
fell from his bicycle. He denies loss of
consciousness, headache, and neck
pain. He complains of severe abdominal
pain (8/10) mostly left upper abdomen.
He is uncomfortable and grimacing with
pain. V/S are pulse 110, B/P 124/68,
respirations splinting and 18. GCS 15.
He is tender in the LUQ. There are no
obvious bony injuries.
You
have attended a 4 year-old girl who
is covered in hives, has stridorous
breathing, audible wheezing, and is very
anxious and distraught. She appears
cyanotic and ashen. The mother states
that the child ate a peanut butter cookie
prior to the hives appearing. V/S initially,
HR 120, RR 30. O2 is applied by NRB.
You have given Epinephrine 0.2 ml. SQ
with no response and are now en route
to hospital.
A
mother calls the ambulance for
her 3 year-old son who has had a
fever (39º C) for 1 day. The child
has leukemia and is on
chemotherapy. His last treatment
was four days ago. The child has
flushed cheeks but otherwise looks
well. V/S are pulse 120, BP 100/65
and respirations 20.
You
arrive and find a 2 month-old
infant carried in his mother’s arms. He
has had a “high” fever for 2 days and
has been given Tylenol with some
relief. Yesterday the baby was irritable
and today the baby is not feeding well
and is lethargic. The baby looks
unwell and floppy. VS are pulse 200,
RR 36. You apply O2 and transport
immediately.
CTAS Level 3
Urgent
CTAS Level 3: Explanation
 normal
vital signs

presenting problem suggests a more serious
acute process occurring

moderate pain(4-7/10) involving head, chest,
abdomen
CTAS Level 3: Physiologic
Assessment
• infant – inconsolable, not feeding or atypical
behavior
• mild respiratory distress, mild stridor
• respiratory rate at the limits of normal range
• heart rate at the limits of normal range
• capillary refill greater than 2 seconds
CTAS Level 3: Usual Presentations
 Head
injury
- alert (GCS 13-15)
- moderate pain (4-7/10)
- nausea or vomiting
CTAS Level 3: Usual Presentations
 Moderate
Trauma:
- head, chest, abdominal pain(4-7/10)
- patients extremity trauma - fractures or
dislocations pain (8-10/10)
CTAS Level 3: Usual Presentations
 Asthma,
Mild/moderate
- short of breath on exertion
- frequent cough
- O2 Saturation > 92 < 94 %
CTAS Level 3: Usual Presentations
 Dyspnea
Moderate
- pneumonia
- bronchiolitis
- croup
CTAS Level 3: Usual Presentations

Seizure:
– brief duration (< 5 minutes)
- known seizure disorder
- new onset
- patient stable and alert
- able to manage airway
- normal vital signs
CTAS Level 3: Usual Presentations
 Vomiting
and/or diarrhea
< 2 years, normal vital signs, looks well
> 2 years, mild to moderate dehydration,
stable vital signs, may look unwell
CTAS Level 4
Less Urgent
CTAS Level 4: Explanation
 stable
vital signs

lower pain scales

patient can wait longer for primary care

most care givers would bring their child to ED
CTAS Level 4: Physiologic
Assessment

Consolable/appropriate but history of atypical
behavior
 respiratory

rate within normal range for age
heart rate within normal range for age
CTAS Level 4: Usual Presentations

Head Injury
- alert (GCS 15)
- no loss of consciousness
- no vomiting, may have headache (0-3/10)
- no neck symptoms
- normal vital signs
CTAS Level 4: Usual Presentations
 Minor
Trauma
- extremity pain (4-7/10 )
- head, chest, abdominal pain (1-3/10)
- lacerations requiring investigations or
interventions
- minor fractures
CTAS Level 4: Usual Presentations
 Abdominal
pain
- history of acute pain (1-3/10)
- the severity of pain does not rule out a
potentially serious problem
- patient should not appear distressed
- start by assuming the worst
CTAS Level 4: Usual Presentations
 Ear
ache
- causes moderate (4-7/10) to severe
pain(8-10/10)
- child may present in severe distress and
may need pain management early and
assigned a higher level
CTAS Level 4: Usual Presentations
 URI
Symptoms
- may present with upper airway congestion,
cough,aches, sore throat are more common
presentations for children.
- fever
- a reminder that “flu” like symptoms can be
serious for the younger population.
CTAS Level 4: Usual Presentations
 Vomiting
and/or Diarrhea
- no signs of dehydration (age >2)
- simple viral gastroenteritis is usually
benign
CTAS Level 5
Non Urgent
CTAS Level 5: Explanation
 often
do not use ambulance

minor complaints

do not pose any immediate risk to the patient

degree of pain is minimal
CTAS Level 5: Physiologic
Assessment

no history of atypical behavior

respiratory rate within normal limits for age

heart rate within normal range for age
CTAS Level 5: Usual Presentations
 Minor
trauma
- contusions, abrasions
- lacerations not requiring suturing or
closure
- minor sprains with minimal pain (1-3/10)
CTAS Level 5: Usual Presentations
 Vomiting
alone, diarrhea alone
- no signs of dehydration
- afebrile
- normal vital signs and mental status (child
is active and sociable, curious of
surroundings)
 You
are encouraged to use your
experience and instincts to “up triage”
priority even it the patient does not seem
to fit exactly with the facts or definitions
on the triage scale.
 “Not
all patients are as sick as they
appear, and not all patients are as well as
they think.”
Case Presentations
A
15 year-old male was hit by a car and
fell from his bicycle. He denies loss of
consciousness, headache, and neck
pain. He complains of severe abdominal
pain (8/10) mostly left upper abdomen.
He is uncomfortable and grimacing with
pain. V/S are pulse 110, B/P 124/68,
respirations splinting and 18. GCS 15.
He is tender in the LUQ. There are no
obvious bony injuries. Case #34
You
respond to a track and field event.
On arrival you note a 17 year-old male
who has collapsed following what was
reported as seizure activity. BP 114/52,
HR 62 irregular, RR 22. GCS 15 and
he is alert and orientated. He reports a
similar event occurring a week ago at
practice. Case #35
 You
respond to a call from the police
dispatch centre. You arrive to find a 42 yearold male who is being restrained from
jumping off the balcony of his apartment
building. He states he is being told to jump.
He has attempted suicide in the past. He
has a history of manic depression and is on
lithium. He is now restrained on an
ambulance stretcher. Case #36
 You
are transporting a 2 year-old who
swallowed a plastic Christmas star.
She has vomited during your
assessment and occasionally gags.
She has no laboured respirations or
stridor. Her chest is clear, and vital
signs are normal. Case #37
You
are called to a shopping center for a man
collapsed. The gentleman was found to be
VSA and after initial defibrillation, you have
return of a perfusing rhythm and the patient
awakens. You package him for transport and
the patient’s condition is as follows: HR 80
and sinus on the monitor with no ectopy, BP
120/70, RR 18 and spontaneous, and GCS
13. Case #38
You
respond to a call from the school nurse.
You arrive to find a 13 year-old male sitting
slumped in a chair. He appears tired avoiding
eye contact. BP 112/60, P 108, respirations
are rapid and deep at 24 breaths/minute.
GCS 15, Blood Sugar is 30 mmol/L. His face
is flushed and you do note an odour of
acetone on his breath. Case #39
You
respond to a call to a private
residence. On arrival you find a 32 yearold female at the bottom of the cellar
stairs. You note this woman to be in the
advanced stage of pregnancy. You also
note bleeding between the patient’s legs.
GCS 15, BP 96/60, Pulse 118. The
patient is moaning, not identifying specific
areas of discomfort. Case #40
You
respond to a call from the local community
centre. You arrive to find a 28 year-old male
sitting on a bench after having sustained an
injury to his left elbow while playing hockey.
He is complaining of pain in his left elbow with
numbness to his left hand. BP 144/90, HR
100, RR 24. You note an obvious dislocation
to the left elbow and are unable to palpate a
left radial pulse. Case #41
You
are dispatched to a residence for a patient
experiencing chest pain and shortness of
breath. Upon arrival you are presented with a
58 year-old male with a previous history of MI
3 year’s ago. Your assessment reveals chest
pain rated as a 7/10, equal bilateral air entry,
BP 160/90, P 110 regular and full, respirations
24 shallow and regular. Skin warm moist and
pale. The patient has taken 2 NTG sprays
prior to your arrival. You administer NTG
spray and ASA. Enroute you administer 2
more NTG sprays. Case #42
You
respond to a call from a nursing home.
When you arrive you note a 79 year-old male
who is incoherent and has a left-sided
weakness. According to the nursing home staff
he has always been fairly active, these
symptoms were a sudden onset. BP 165/105,
HR 82 irregular, RR 22. He is agitated and
refuses to lie down and will only sit up on the
stretcher. He also will not leave nasal prongs
for oxygen delivery. Case #43
You
respond to a residence and are met by
a mother carrying her three-month-old
child. The mother states that the child has
been vomiting, and refuses to eat or drink
anything. You note the child is breathing
fast and respirations are difficult to assess,
has a runny nose, cough, and a fever. The
mother states the child is lethargic. The
child is pale and limp in mother’s arms.
Case #44
You
manage a 32 year-old patient with a history
of asthma and sudden onset of shortness of
breath after exposure to a cat. She has audible
wheezing and her initial V/S are HR 110, RR 32
and laboured, BP 130/70 and O2 sat 92%. You
treat her with supplemental oxygen and with
nebulized Salbutamol. After one treatment the
patient feels much improved and questions if
she needs to go to the hospital. After a
discussion with the patient she agrees to go to
hospitals and her V/S are HR 90, RR 22, BP
130/70, O2 sat 97%. Case #45
 You
are dispatched to a nursing home to
transport a patient to the emergency
department. You arrive to find a 92 year-old
male who has been vomiting all night. He is
pale, skin is dry and you note that the
emesis is coffee ground colour. The patient
is conscious although disoriented. BP
108/70, HR 96, RR 16. Case #46
You
are dispatched to a local beach for a
patient who has been stung by a bee. Upon
arrival you are presented with a 14 year-old
male patient who is short of breath with
hives and facial swelling. He has obvious
wheezes, BP 100 by palpation, P 100 weak
and regular respirations, 24 shallow and
irregular. You immediately administer
0.3mg of Epinephrine 1:1000 and begin a
Salbutamol treatment 5 mg.
Case #47
 You
are called to a residence of a 65 year-old man
complaining of sudden onset of shortness of breath
three hours ago. He denies CP. The patient has a
history of angina and CHF. His VS are HR 96, RR
32, BP 188/112, O2 sat 92%, crackles to mid lung
fields and no pedal edema. You manage the
patient with positioning, oxygen, cardiac monitor
and nitrates. After spending 15 minutes extricating
the patient from his walk-up apartment his V/S are
HR 92, RR 24, BP 164/96 O2 sat 96% and the
patient states his shortness of breath has improved
moderately. Case #48
 You
respond to a senior citizen’s group home
where you find an 80 year-old female who
has sustained a fall. She states the floor was
wet and she slipped. You note that her left
leg is shortened and outwardly rotated. She
keeps rubbing her left hip area stating it is
quite painful to move. She only takes a
water pill every other day. V/S are BP
165/90, HR 90, RR 18, pedal pulses are
present in her left leg. She is immobilized
and transferred onto the stretcher. Case #49
You
are dispatched to a local arena for a
patient short of breath. Upon arrival you are
presented with a 27 year-old male in obvious
distress. You learn that the patient is a known
asthmatic and has tried his puffer with no
relief. BP 130/80, P120 weak and regular,
respirations 26 shallow and irregular skin- pale
cool and moist. You immediately administer 5
mg. of nebulized Salbutamol with a second
treatment enroute. Case #50
You
arrive at a residence of a 28 yearold woman with known diabetes for
who is comatose (GCS 8), HR 110, BP
120/60. You find her capillary glucose
to be 2 mmol/L. After treatment the
woman has regained consciousness
(GCS 15), HR 80, BP 120/60. You
prepare for transport. Case #51
You
arrive and the mother states that
her 18 month-old child has had a fever,
vomiting and diarrhea for 2 days. He
was at the after hours clinic last evening
and told to continue with Tylenol and
fluids. This morning the child “looks
sick.” The child has not voided
overnight. His pulse is 145, respirations
35. You apply oxygen and transport.
Case #52
A
39 year-old female was on a ladder
fixing her windowsill and fell eight feet
onto her patio deck. She landed on her
back, had no LOC. She has no obvious
injuries and her only complaint is lower
back pain. No medical history. She is
unable to move or feel her legs. BP
130/84, P 90's and regular, respirations
16, full and regular. Case #53
A
9 year-old female complains of a
right earache that started earlier
today. She was given Tylenol with
some relief. She is tearful and
having pain (7/10). Vitals are
temperature 37.9º C, pulse 80, and
respirations 16. Case #54
You
respond to a school where you are
directed to the health nurse’s room. A 16
year-old is accompanied by his football
coach. His coach states that his player
was tackled and now has severe
abdominal pain. His colour is pale, he is
diaphoretic and his V/S are BP 90/54,
pulse 108, respirations 22. A large bore
intravenous is started with N/S tkvo.
Case #55
 You
are dispatched to a residence for a patient
experiencing chest pain. Upon arrival you are
presented with a 68 year-old male patient who has
taken 3 NTG with some relief. BP 140/90, P 88 reg.
and full, respirations, 16 deep and regular, skin pale
warm and dry. You administer 1 NTG at the scene and
begin transport. In the ambulance you administer
2x80mg ASA and a second NTG. Approximately 5 min.
from the hospital the patient says he feels very strange
and becomes unconscious. Your assessment reveals
the patient to now be VSA. You attach your defibrillator
and administer 2 shocks and have a return of
spontaneous circulation. Case #56
You
respond to a call from a school. You arrive
to find a 6 year-old girl who is crying. The
teacher states that she fell in the schoolyard
and struck the side of the sandbox. The girl’s
face is covered with dried blood and she has
not stopped crying. You note the child is alert
and crying, respirations are unlaboured and she
is pale. You also note a deformed right
forearm. The arm is splinted and you note a 4cm. laceration above the left eyebrow once the
face is cleaned. V/S GCS 14, P 120,
respirations 18, BP 100/56. Case #57
 You
respond to a residence where you find a 46
year-old female who has a decrease level of
consciousness and who is in respiratory distress.
She has a history of ovarian cancer and has been
on palliative care at home. Although her wish was
to stay at home her family is requesting she be
brought to the emergency department because her
“breathing has changed.” She is pale, diaphoretic
and cool to touch. Her extremities are cyanotic.
She has a saline lock for analgesic administration
and she receives oxygen at 4L/minute via nasal
prongs. V/S are BP 110/72, Pulse 86, respirations
32. Case #58
You
are dispatched to a residence for a
patient complaining of SOB. Upon arrival you
are presented with a 70 year-old male patient
with a 15-year history of COPD. The patient
tells you that he has been more short of
breath than usual over the past day. You
observe noisy breath sounds on auscultation
with decreased air entry. BP 140/90 P 88
regular and full, respirations 24 shallow and
irregular. You administer Salbutamol 5 mg.
Case #59
You
are presented with a 26 yearold male, feeling depressed, not
suicidal. He has a history of mental
illness. He denies taking pills or
alcohol. Vitals are normal. Case
#60
You
are dispatched to a scene in an industrial
area. On arrival you note a 24 year-old male
who has been assaulted. He has several facial
lacerations and his left eye is swollen shut.
The bleeding is controlled. He denies any loss
of consciousness. He is alert and orientated.
BP 166/90, HR 102, RR 20. GCS 15. Case
#61
 You
respond to a call from a 30 year-old
female who states she has taken a large
amount of Tylenol capsules. She is
orientated, alert and her V/S are BP 110/62,
HR 88, RR 14 and GCS 15. She changes
her mind about going to the hospital and after
some encouragement from her roommate
she finally consents to going to the
emergency department. Case #62
You
respond to a call to a private residence.
On arrival you find a 63 year-old, in a state of
undress sitting on the steps leading into the
home. The patient is leaning forward and
you note he is displaying indrawing
intercostal muscles and prolonged forced
expiratory phase. The patient responds to
questions asked with one-word answers.
You note an unlabeled inhaler by his side.
BP 148/88, respirations 14, P 76. Case #63
You
arrive at a home where you
are met by a mother carrying a 1
year-old who fell off the changing
table only moments ago. The baby
is alert, sociable and sucking on his
bottle. On examination it is noted
that he has a reddened temporal
area. Case #64