Accompanying notes for my tutorial in the Preparatory course for Pre-interview Assessment for Emergency Medicine Master of Medicine (PIAEM) program 2015

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PIAEM 2015 Dr. Chew Keng Sheng
Pediatric Assessment In Emergency
Department
Physiologic and Anatomic Considerations
1. Head and Neck
a. Disproportionally larger and heavier head
i. Children tend to land head first ­ risk of head injury
ii. Relatively elastic cervical spines and can have spinal cord injuries without
radiologic evidence of injury
2. Airway and Respiratory system
a. Prominent occiput: The proportionally larger occiput in infants and younger
children results in ‘natural’ neck flexion in the supine position.
i. Anatomic airway obstruction
ii. obstructing laryngoscopic view of the glottic opening
b. Epiglottis:
i. Compared to adults, epiglottis is relatively large and floppy in children,
particularly those younger than three years of age.
ii. It is angled more acutely with respect to the axis of the trachea.
iii. Therefore, it projects into the airway and covers more of the glottic
aperture
iv. Straight blade is a suitable option
c. Tongue is larger relative to the oropharynx ­ risk of airway obstruction
d. Trachea:
i. The short trachea of the pediatric patient predisposes to right mainstem
bronchus intubation or inadvertent extubation
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PIAEM 2015 Dr. Chew Keng Sheng
ii. The narrower trachea also causes its airway resistance to be relatively
higher compared to adults. This is because the airway resistance is
inversely proportional to the lumen radius to the fourth power.
3. Cardiovascular system
a. Children have compensatory mechanisms that can support blood pressure even
when cardiac output is decreasing
b. They have the ability to increase their heart rate and peripherally vasoconstrict to
shunt blood centrally
c. Therefore, ​hypotension is a late finding of shock
d. The first sign of shock is tachycardia.
i. Note: tachycardia is nonspecific and may be due to fever, pain, or anxiety
e. Unexplained tachycardia in a calm or sleeping child is concerning
f. Bradycardia in ill children is especially ominous and may signal impending
cardiac arrest.
g. Pulse rate <60/min with signs of poor perfusion despite adequate
ventilatory/oxygen support is an indicator to begin CPR
4. Musculoskeletal system
a. Weakest part of a growing child's bone is the physis, or growth plate, leading to
risk of fracture
b. Salter­Harris Classification
i. Mnemonic ​S­A­L­T­​e​­R ‘C’​lasses
ii. S​ = ​S​eparation of physis from metaphysis (Type I)
iii. A = A​bove the physis (meta­physis) fractured (Type II)
iv. L = L​ower than physis (epi­physis) fractured (Type III)
v. TR​ = Through and through from above and below the physis (Type IV)
vi. C​ = Crushed (Type V)
c. Physeal injuries should be considered in children even with normal radiographs.
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PIAEM 2015 Dr. Chew Keng Sheng
5. Temperature regulation
a. Infants and young children have a large surface area–to–body mass ratio
b. Therefore, they lose more heat to the environment than adolescents and adults.
c. Maintenance of a stable body temperature can be a significant metabolic demand
in young infants, especially those stressed by injury or illness.
Non-accidental Injury (NAI)
1. Suspect NAI
a. in the presence of multiple ages of bruises at the body that do not correlate with
history from parents or guardian.
b. Delayed in seeking treatment.
2. Malaysian Police statistics for year 2006 shows that 89% of the child sexual abuse
perpetrators are people known to the victims. Out of this 89% of the perpetrators, 53% of
them are parents.
3. Those who don’t cruise, rarely bruise:​ A cross­sectional survey of children (<age of 3
yrs) on evaluation of bruises of children in general found that:
a. 203 out of 973 children had any bruising
b. In those <6/12 of age, only 0.6% had bruising
c. 2.2% of non­mobile children of any age had bruising
d. Once began cruising and walking, bruising incidence increased substantially
i. Especially bruises on anterior shins, knees and forehead; no bruises
noted to the hands or the feet, and bruising to the trunk was rare
e. Ref: Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those
who don't cruise rarely bruise. Puget Sound Pediatric Research Network.
Archives of pediatrics & adolescent medicine. 1999;153(4):399­403.
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PIAEM 2015 Dr. Chew Keng Sheng
4. The TEN­4 Rule:
a. In this derivation study, ​TEN­4​ rule has been shown to have a sensitivity of 97%
and a specificity of 84% in identifying concerning bruises:
i. TEN­4​ is a mnemonic that stands for
ii. “4”​ = any bruising in a suspicious body region in a child <4 years of age
should warrant further investigation
iii. suspicious body regions defined by “T­E­N”:
1. T​ = torso (chest, abdomen, back, buttocks, genitourinary region
and hip)
2. E​ = ears
3. N​ = neck.
iv. Ref: Pierce MC, Kaczor K, Aldridge S, O'Flynn J, Lorenz DJ. Bruising
characteristics discriminating physical child abuse from accidental trauma.
Pediatrics. 2010;125(1):67­74.
5. Dating of age of bruises have been shown to be inaccurate especially in emergency
department. More important than estimating the age of the bruises is the proper
documentation of the bruises in emergency department.
a. Bruising should be documented clearly in the medical chart with the
i. location
ii. size and
iii. pattern (if present) all described in detail.
b. Preferably photo­documentation with a ruler or measuring tape if possible.
Initial Evaluation
1. Use ​Pediatric Assessment Triangle (PAT) Model​ (Dieckmann et al, 2010)
2. The purpose of PAT is to decide: “sick or not sick?” heuristic
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PIAEM 2015 Dr. Chew Keng Sheng
3. 3 components: ABC (Appearance, work of Breathing, Circulation to skin)
4. A = ​A​ppearance
a. Observe interaction of child with parents from a distance. Minimal disturbance to
child.
i. Mnemonic: ​TICLeS ​(“tickles”)
1. T​ = ​t​one: is chid moving all limbs? Or lying motionless?
2. I​ = ​i​nteractiveness: is child attentive to environmental stimuli?
3. C​ = ​c​onsolability: is child irritable?
4. L​ = ​l​ook/gaze: blank stare?
5. S​ = ​s​peech/cry: Quality of cry?
ii. Interacting well with parents?
iii. Irritability is an early sign of inadequate brain perfusion, and this may be
followed by lethargy and then coma as the poor perfusion continues
iv. Observe quality of the cry: persistently high­pitched or irritable cry is
concerning for central nervous system disease, such as meningitis.
5. B = Work of ​B​reathing
a. Observe position of child: sniffing position in an attempt to decrease airway
resistance? Tripoding suggests severe respiratory distress, e.g. in epiglottitis?
b. Observe breathing patterns:
i. Retractions in the suprasternal, supraclavicular, intercostal, and subcostal
regions suggestive of increased work of breathing
ii. Seesaw breathing (breathing pattern in which the abdomen moves
outward and the chest moves inward during inspiration) suggests
impending respiratory failure.
c. Observe quality of cry/voices:
i. hoarse voice suggests croup
ii. muffled or “hot potato” voice suggests peritonsillar abscesses
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PIAEM 2015 Dr. Chew Keng Sheng
6. C = ​C​irculation to skin
a. Visual inspection of the skin can provide clues to the overall cardiovascular
status
b. Early compensated shock is characterized by
i. Pale skin? Due to peripheral vasoconstriction and shunting of blood to the
brain and other vital organs ­ suggests early compensated shock
ii. Mottled skin? If initial shock state not corrected, skin may become
mottled.
1. Note: Mottling is a random pattern of vasoconstriction and
vasodilation in adjacent areas of the skin. Do not confuse this with
cutis marmorata, a lacy pattern which is a normal finding in young
infants due to cool environments.
2. In contrast to infants with mottling, infants with cutis marmorata
will be otherwise well appearing, and the skin findings will diminish
or disappear if the infant is bundled or placed in a warm
environment.
iii. Cyanosed skin?
1. Maybe present in children with chronic cyanotic congenital heart
disease
2. If cyanosis is a new finding for the patient, suggests respiratory
failure or decompensated shock.
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PIAEM 2015 Dr. Chew Keng Sheng
Pearls in Pediatric Assessment
1. Children commonly develop respiratory failure prior to cardiac arrest. This is because
most cardiac arrests are due to primary respiratory failure. Therefore, rescue breathing is
still recommended during resuscitation of children.
2. Cardiopulmonary arrests in children generally follow ​progressive deterioration​ and
usually do not occur as sudden events unless it is a case sudden infant death syndrome
(SIDS), major trauma, and certain primary cardiac events.
3. The two­thumb method is preferred to the two­finger method for neonate/infant chest
compression. In two manikin studies, the two thumb technique has been shown to
produce better compression depth and compression pressure (Udassi et al, 2009) and
higher mean arterial pressure (Dorfsman et al, 2010) compared to the two­finger
method. Nonetheless, AHA recommends that for a lone rescuer, the two­finger method
is recommended.
4. Not all respiratory failure cases are associated with respiratory distress. Respiratory
failure may be present without respiratory distress. This can occur as work of breathing
may appear normal or even reduced (hypoventilation) in children with a reduced level of
consciousness (ingestion, metabolic derangements, head trauma), neuromuscular
dysfunction (muscle disease), or fatigue before respiratory failure occurs. Look for trend
of PaCO2. Increasing PaCO2 in the presence of hypoventilation suggests impending
respiratory arrest
5. Check a rapid bedside glucose level for any young child with altered mental status if the
cause is not immediately obvious.
6. Although cardiac chest pain in children is rare, chest pain induced by exercise or
associated with fever, or accompanied by an abnormal finding on physical examination
is concerning. Hypertrophic cardiomyopathy can cause chest pain induced by exercise.
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PIAEM 2015 Dr. Chew Keng Sheng
Myocarditis or pericarditis can present with chest pain associated fever. Pericarditis
causes a sharp, stabbing midsternal pain, relieved when the patient sits up and leans
forward.
7. Crying and irritability in an infant may indicate a life­threatening condition, such as
meningitis, or only colic. A careful history and physical examination are essential to
detect treatable causes for crying in infancy.
8. The height of the fever by itself is a poor predictor of serious bacterial illness. Most
studies show limited usefulness of the height of fever as a predictor of serious bacterial
illness. In an otherwise healthy child even temperatures higher than 39°C have relatively
low sensitivity (10­14%) and predictive value (4­40%) for serious illness in infants over 6
months. Better predictors of serious bacterial illness include age of child, appearance of
child, and peripheral perfusion. The presence or absence of fever is more important than
the height of the temperature itself. Any child with fever, regardless of the height of the
temperature, should receive a thorough evaluation . (Ref: National Institute for Health
and Care Excellence: Assessment and initial management of feverish illness in children
younger than 5 years: Summary of NICE guidance. BMJ 2013;346:f3764)
9. Urinary tract infection is the most common bacterial infection in febrile infants less than 2
months old and they can present with vague and non­specific symptoms such as poor
feeding, decreased urinary output, lethargy, increased sleeping, vomiting, failure to
thrive, and jaundice.
10. The absence of abdominal tenderness does not exclude intussusception.
Intussusception is the most common cause of acute intestinal obstruction in a child
between 3 and 12 months of age but it is a dynamic process, i.e., the bowel can
telescope in and out, abdominal pain may be intermittent. The classic signs and
symptoms of intussusception—abdominal pain, palpable abdominal mass, and red
currant jelly stool—are found in fewer than 50% of cases. Furthermore, a currant jelly
stool is a late finding, because it implies that bowel necrosis has occurred. (Ref:
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PIAEM 2015 Dr. Chew Keng Sheng
Lockhead A, Jamjoon R, Ratnapalan S: Intussusception in children presenting to the ED.
Clin Pediatr 2013;52:1029; Mandeville K, Chien M, Willyard PA, et al: Intussusception:
Clinical presentations and imaging characteristics. Pediatr Emerg Care 2012;28:842.)
11. Young infants with meningitis may not have a stiff neck until the infection progresses and
it is usually seen after 18 ­ 24 months of age. Neonates with meningitis rarely presents
meningismus or nuchal rigidity. The most common symptoms of meningitis in neonates
are lethargy, irritability, poor feeding, dyspnea, and apnea. Fever can also be uncommon
in neonates. (Ref: Heath PT, Nik Yusoff NK, Baker CJ: Neonatal meningitis. Arch Dis
Child Fetal Neonatal Ed 2003;88(3):F173­F178.)
12. In an infant with stiff neck, fever ­ also think of retropharyngeal abscess. Usually these
patients have fullness on one side of the neck and refuse lateral neck movement. Get a
lateral neck radiograph
13. An abnormal capillary refill time is probably the most reliable sign for predicting
dehydration in children. However, a combination of examination signs is better than any
individual sign. The presence of two or more of the following four clinical measures
seems most reliable in predicting at least 5% dehydration: 1) “Ill” general appearance 2)
Lack of tears 3) Capillary refill time at the fingertip longer than 2 seconds 4) Dry mucous
membranes (Ref: Gorelick MH, Shaw KN, Murphy KO: Validity and reliability of clinical
signs in the diagnosis of dehydration in children. Pediatrics 1997;99:e6.; Steiner MJ,
DeWalt DA, Byerley JS: Is this child dehydrated? JAMA 2004;291:2746­2754.)
Further resource:
Go to my post in Storify.com on more collated internet resources on pediatric resuscitation:
https://storify.com/cksheng74/pediatric­resuscitation#publicize
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