Sick Or Not Sick? BLS Assessment of the Pediatric Patient

An agency I used to work for had a separate pediatric bag. The person in charge of supplies put a zip tie on it to indicate it was stocked and didn’t need to be checked. Months would go by at times without the zip tie being cut—we didn’t run a lot of pediatric calls. It also meant people weren’t going through the bag to get hands-on with the equipment during training. 

Pediatric calls make many providers more nervous than adult calls for many reasons, including lack of frequency, less familiarity with pediatric vital signs, and, especially for providers who aren’t parents or caregivers, a lack of practice interacting with kids. This article provides a brief review of assessing the pediatric patient to determine if they are sick.

A Five-Step Process

In EMS we define an infant as birth to 1 year old. A child is defined as 1 year of age until the onset of puberty, typically between the ages of 11–14. An adult is one who has reached puberty or beyond. Of course, each age range presents differing developmental milestones and vital sign ranges.

Your assessment begins before you arrive on scene, with any prearrival details from dispatch. Scene safety, PPE protections (mask, gown, gloves and goggles per your local protocols), and situational awareness always apply.

Step 1—What do you hear and see when you enter the room? What is your overall impression? What are the parents or caregivers doing?

Step 2—Look at the patient. What is the breathing rate? What is their skin color? Is there cyanosis (a particularly bad sign in kids)? What is their level of consciousness? Are there any rashes or hives? Swelling? Any obvious bleeding, fractures, or deformities?

Step 3—Listen. What do you hear? Stridor? Stridor with crying? Abnormal cry? Asthmatics that are too tight to wheeze? Is this a septic child with a weak cry? Start without a stethoscope and then listen with it.

Step 4—Feel. Check brachial pulses. Is the patient tachycardic? Bradycardic (brady = bad)? Is there normal capillary refill? Any bleeding? Skin temperature? Is the patient febrile?

Step 5—What can the patient do in terms of movement? In terms of normal development, the following are benchmarks for infants:

• 2 months: Smile;
• 4 months: Roll over;
• 6 months: Sit up;
• 9 months: Cruise/crawl;
• 12 months: Walk.

Vital Sign Tips

• Be careful with pulse oximeter placement. Use a sticker if possible and put it on a toe. Avoid patient movement for accuracy.
• Don’t bother with a blood pressure for children under 2. It doesn’t provide much prehospital data, crews often lack accurate equipment to measure it and it is especially hard to auscultate on an infant.

Airway

• Airway is always the most important (aside from severe injury/bleeding).
• Mild swelling can narrow an infant’s airway, and infants normally have an irregular breathing pattern.
• Maintain the head in a neutral “sniffing” position forward of the shoulders.
• Do not hyperextend the neck—you will compress the airway.
• Children with significant respiratory distress will tripod. Give high-flow oxygen and do not move them from that position unless they are unconscious.
• Signs of potential airway compromise include tripoding, nasal flaring, and chest retractions. 
• Expose the child's accessory muscle use to visualize the chest and auscultate the lungs. 

Breathing

• A wheeze may indicate asthma or allergies.
• Crackles indicates a respiratory infection or possibly pneumonia.
• Grunting indicates impending respiratory failure.
• Severe respiratory distress usually precedes cardiac arrest.
• Providers need to aggressively manage the breathing with supplemental oxygen, BVM, and/or oral airways if needed. If the child will not tolerate a mask, consider using a piece of oxygen tubing as “blow by” near a favorite stuffed animal.

Circulation

• Circulation issues usually stem from volume problems, not cardiac events. Volume problems can include dehydration, blood loss, and high fever.
• Bradycardia is always a critical issue.
• Infants and children will compensate to maintain blood pressure until they’ve lost 25%–33% of their volume and then decompensate quickly.

Disability

• Constant observation of the child is needed.
• A bulging anterior fontanel is a bad sign. It is a result of increased intracranial pressure or intracranial and extracranial tumors. A sunken fontanel usually is a sign of dehydration.
• Infants should have a rooting reflex. This is a reflex seen in normal newborn babies, who automatically turn the face toward any stimulus and make sucking (rooting) motions with the mouth when the cheek or lip is touched. The rooting reflex helps ensure successful breastfeeding.

Fever

One of the most common reasons EMS is called for pediatric patients is a high fever, sometimes accompanied by a febrile seizure.  

A pediatric fever is defined as a rectal temperature of 100.4ºF or greater. If the patient is seizing, control the airway and breathing. BLS treatment includes exposing the patient and cooling them with a damp washcloth. Febrile seizures are usually self-limiting, and patients should be transported to the hospital for an evaluation. Children with inserted medical devices are at greater risk for infection/sepsis and subsequent fevers.

Managing Parents

Remember that parents need to be reassured and managed as well. They are concerned about their child. Give them a task to do, such as dressing the child or wrapping them in a blanket. They are also your best source of medical history and what is normal for their child. Use them as a resource.

Keep calm and keep them informed. Remember, maintaining a calm demeanor typically calms the parents!   

Sidebar: Red Flags

Several signs should be seen as red flags to tell you the infant or child is sick. The acronym CATNITS will assist with remembering this.

C—Congenital problems (taking a detailed medical history from the parent or caregiver will be important);

A—Reaction to allergies (common allergens are nuts, penicillin, and latex);

T—Trauma (e.g., fall, penetrating wound, blunt force, MVC);

N—Neoplasm (cancer);

I—Ingestion of nonfood items (cleaning agents, toys);

T—Toxins; bring a sample to the ED if you can. Call the national poison control hotline (800-222-1222) en route but do not delay treatment to make the call.

S—Social/psyche (threat to themselves or others): Is there a history of depression or mental illness? Gather medication history. If there is a threat of self-harm, follow local protocols regarding law enforcement.

Barry Bachenheimer, EdD, FF/EMT, is a frequent contributor to EMS World. He is a career educator and university professor with more than 33 years in EMS and fire suppression. He is currently an EMT with the South Orange (N.J.) Rescue Squad, a firefighter with the Roseland (N.J.) Fire Department, and an instructor at the National Center for Homeland Security and Preparedness in New York. Reach him at bbachenheimer@albany.edu.