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Although it may require the assistance of the parent or caregiver to expose the child’s chest, also assessfor other signs of respiratory distress such as retractions. Retractions are a sign of increased work of breathingthat results in dramatic changes of pressure within the chest. As the child actively tries to inhale, a higher level ofnegative pressure is created in the chest. Though this may help the child to move air into the chest despite asevere asthma attack or airway obstruction, it also causes the tissue around the bony areas of the chest to bepulled in toward the chest during inspiration. As a result, these areas appear to “pull in” or “retract.” Retractionsare most commonly seen in between the ribs (intercostals retractions), above the collar bones or clavicles(supraclavicular retractions), along the lower border of the rib cage (infracostal retractions), or just beneath thesternum (substernal retractions).Finally, in infants a few other specific signs may be seen that suggest an increased work of breathing.Although infants may normally have “abdominal breathing” during the first few months of life – using theabdominal muscles and diaphragm only to move air – so called “see-saw” respirations are always consideredabnormal. This is when the chest wall and the abdomen move in opposite directions during breathing. Nasalflaring and head bobbing are also signs of an increased work of breathing in infants.So putting this all together, the idea is that you can quickly (in less than 30 seconds) assess a child withoutever touching them and yet with enough information being gathered to quickly decide if the child is “sick” or“not sick.” Upon approaching the child, simply ask yourself: Are there any signs of an increased work ofbreathing? Does the blood flow to the skin appear normal or abnormal? Does the child appear “irritable” orlethargic? If any of these three things are abnormal, the child should be considered “sick.”Physical AssessmentOnce you have completed a rapid, general assessment of the child, your history-taking and exam shouldprogress as it would for any other patient, with a few exceptions. As we noted above, the involvement of the childin the history should vary, based upon age. Particularly in younger children, more “aggressive” parts of yourexam should be saved until last (unless they are urgently needed – i.e. breath sounds in a “sick” child withrespiratory distress). And even your body position should be altered slightly.Remember that you are a medical professional, but to young children in particular, there may be anirrational association with medical care and pain (injections, immunizations, etc). Also, the fact that you wear auniform may be a source of fear for some children.Both of these things can be overcome (to some degree) by keeping yourself at or below the eye level ofthe child, by talking to them rather than just about them, and by interacting with them at an age-appropriate level.Vital SignsRecognizing abnormal vital signs in a pediatric patient is particularly important. Though it can be difficultto memorize all of the tables that have been made to describe normal and abnormal vital signs in children, a fewgeneral rules will help you to again distinguish “sick” from “not sick.” It is also important to remember that aSeptember 2009 – Journal CME Newsletter page 10 of 18
single set of vital signs may reveal very little about the condition of an ill or injured child, and repeating themoften is important in order to identify trends of concern.Blood Pressure This can be difficult to assess, particularly in the very young. And there are multiplereferences to use in determining if a pediatric patient’s blood pressure is normal. But two rules will help you todistinguish normal from abnormal. On the high end, a pediatric patient’s blood pressure should never exceed asystolic of 140mmHg. Such a blood pressure may be an early sign of head injury or other illness. And on the lowend, a pediatric patient’s systolic blood pressure is considered to be critically ill if it is less than 70 + (age x 2).Heart Rate The range that you may see in a pediatric patient includes some impressively high and lownumbers. Remember that when the rate is particularly high, auscultating the chest (listening to the heart) is thebest way to count.Bradycardia (slow heart rates) are concerning for the very late stages of shock or severe hypoxia and mustbe immediately addressed. In general, heart rates are considered to be critically low at a rate lower than 110minus ten points per age group. So, for infants, you should be concerned if the heart rate is less than 110-10, or100. For toddlers, 110 – 20 = 90; for preschoolers, 110-30 = 80; for school age children, 110-40 = 70; and foradolescents, 110-50 = 60.Tachycardia is one of the first signs of a severe underlying illness or injury. And the maximum heart ratethat each of us can achieve is determined by age. As a rule, a patient’s maximum heart rate should never exceed“220 minus their age.” This means that infants can (and do) achieve heart rates in excess of 200 when theyexperience severe illness or injury. And these same rates are possible in all pediatric patients.(Paramedics: This issue of tachycardia is particularly important to note. As you remember, PALSsuggests that you should be concerned about a supraventricular tachycardia in pediatric patients with a heart rate>180 or an infant with a heart rate >200. But in looking at your patients over the past five years, VERY FEWsuch patients actually had a supraventricular tachycardia. Most (>95%) had some other illness or injury that wascausing a sinus tachycardia, not a supraventricular tachycardia. So, when faced with such rates in pediatricpatients, make sure that you look for an underlying cause before treating the rate. That rate could be keepingthem alive!)Respiratory Rate The respiratory rate should be counted while not actively listening to breath sounds and,ideally, when the patient is not crying. There are no equations that are typically used to remember the highs andlows of normal pediatric respiratory rate, but you really only need to remember three ranges. Infants typicallybreathe 40-60 times per minute, toddlers 25-40 times per minute, and children between toddlers and adolescentshave a range from 20-35.One note about assessing the respiratory rate of infants: remember that, particularly in young or prematureinfants, their respiratory pattern may normally include pauses, or periods of apnea, that last for up to 15-20seconds. For this reason it is important to assess an infant’s respiratory rate for a full minute.September 2009 – Journal CME Newsletter page 11 of 18
Page 1 and 2: Continuing Medical Education - News
Page 4 and 5: FDNY ALS Division Coordinators• C
Page 6 and 7: In assessing pediatric patients, it
Page 8 and 9: medical history or cooperate fully
Page 12 and 13: Pediatric PotpourriSince we are on
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Page 17 and 18: Citywide CME - September 2009Sessio

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