cha7ter1

lxlTlALAssEssMEf{T
c

findings sug-
syrnptoms' or physical
trauma
lntro du ctio n $est sPinal
. B : Breathin$
Asystemati" rt{";il"#l"t n"u,-
tro":-:', . C : Circulation
assessmentof every L1t:(-
starus N
atric patient is necessary
f"I
f"".9:i":g o D = Disability or neurologic
identifiiing
life-threatenin$ conoitions' .l : ExPosureand environrnental
and injury' and heat loss
indicators of illness on Joottot io Prevent
l.r.t"i"i"g priorities of carebased
d;.*#irt findings''atttrglen!e SecondarY assessrnerrt
*"r"J,t "t chiidrenpresen:Yitl 1:1-^1
O t:1:X:,? . F : Full set of vital signs'
including
.rn.rg.n,iilnessor injury'
i ratt- weight, and familY Presence
f)ir ii,, i ir e s t" t.*.-ttr that cardiopulmonary
r G : Give comfort measures
rt '' ) -
a sudden event
On courPletion of
this lit" in .ftifaten is rarely and
is the end result of
a pro- . H : Head-to-toeassessrnent
chaPter, the learrer i n.t, or
"-.st
deteriorating respiratory history
should be abie to: ;;;ttt"1t
"rir.ulu,ory
function'2 o I : Inspect Posterior surfaces
1.I)iscuss the comPo-
nents of a pedialric
primary assessflent'
l*'in{:i Pri rrrar\/ Agsessllrellt
#n';ffI":ffi'#'3:ff
2. Correlate li fe-threat-
s'ith
:+*::l;;;1;U#
""r"'":';;i",
able to raPidlY Pro\1d
The PrimarY assessment cewt^7
-i:O::::..t
enin$ conditions
the sPecific colrrpo- ;;,.';::f:
;;;;; l.?ll';f:,H:}il l assessmentot tne ain^'/ay.wirh
.oj". tottlt zatlorl
or maintenance or
traunl i:'::t-
nent of the PrimarS' and evaluation'' Utill zattonrn'hen
assessment' *.*""::'r':i:1;l:;"?'J#:*"'
eachchild helPs ensr
,ilJti"t'it n'1'-10'1Y
it"'itlu,il" "ln';g'circulatio and exPosur: w1m
3.Desffibe intewenuons lr rr.*otogic status'
Interventions to
neededto managelife-
fhreatenin$ conditions
*,',::ml"ff f :::xI*J",ioul"''u
*1:::r-
environnrental control'
;;;; ;t life-threatening
conditions

found durin$ the

thases,the PttT"Y
into-w" t" Plrformed before
further
orrautyassessments' Both phasesc^fl De The interven-
marv assessnlent' resus- u*.ar,*""t is continued'
-".i
t"rrr l*a r'vithinminutes.unless ;;;;; tsted in order 'f Pri'riq''
are required'
rienrsof a Pedirn'ic
-- ciratlre-![94!]{es
srcorrdar;assesslllent' AirwaY
5. Evaluate the
A Guiclerc InitialAssessmenr
the^
effeetl'r'ertessof nursing ruo follou'in{ mnemonic describes Assessrnent
initiai assessmentoI
inten'entions as related components of the patient's aim'ay'
The materials pre- Inspect the ped'iatric
to desiredPatient the pediatric pauent' Ar..t. for the fo1lor'ving'
represent pediattic patient
outcomes' ,."t.a in this chaPter r Vocnlization: Can the ;I
secondary
Pti*utY and
"""-p,J;"tlt'" t iko,"ryt
assessments' an unrespon-
o Ton9ue obstruction in
trtitr,*; assessment sive Pediatric Pattenr
objects"such as
. *o." teeth or foreign
.- A : Airway rn'ith simultaneous.cerv.l- oroPharynx
srnall toys' in the
l".G to-r'iti^tion for anyinjured ;;;t
of inlury or hiPoPharynx
childwhosemechanism r,
 . Vomifus, bleeding, or other secretions in the mouth
r Edema of the lips and,/ortissues of the mouth
. Preferred posture (e.9.,the tripod position is charac-
terized by the pediatric patient sitting up, leaning
. forw-ard,with the.neck extended and head tilted up in
/,
an effort to miximize the airwaY)
/ r Suction the nose of the youn$ infant with nasal
o Drooling (in children other than teethin$ infants)
lt , secretions.
. Dysphagia(difficulty swallowing)
o Abnormal airway sounds such as stridor, snorin$, or
gurglin$. (Inspiratory sounds are characteristic of
extrathoraci.cor upper airway causesof obstruction'
Expiratory sounds are characteristic of intrathoracic
or lower respiratory fract causesof obsfruction')
Intetventions
Airway patent c b fl (d{ S\ctlri f tZtrilc'r
o For any pediatric patient whose mechanism of injury
symptoms,or physicalfindin$s su$$esta possiblecer-
vical spine injury, manually stabilize the cewical
spine or maintain spinal stabilization if completedin
the prehospital environment. A11ainvay maneuvers
for these children must be performed with the cewi-
ca1spine in a neutral position to prevent secondary
injury to the sPinal cord/column.
. If a child is alvake and breathin$, he or she may have
as-qumeda position that maximizes their ability to
maintain a spontaneousairway. A1low the child to
maintain this position or a position of comfort'
Ainuay partialty or totally obstructed
o If the pediatric patient is unresponsive andlor unable
to maintain a spontaneousairway, position the pedi
atric patient (sniffin$ position) and manually open
the ainvay. Techniquesto open or clear an obstructed
airway durin$ the primary assessmentinclude
- Jaw thrust
- Head tilt-chin lift (difficu1t to do in the youn$er
child). Do not use this technique if trauma is
suspected.
r Infants and youn$ children have a lar$e occiput;
positioningthem supine on a bed or backboard
may causetheir cewical vertebrae to flex anteri-
or1y.Flexion may contribute to airway
compromiseor decreasethe effectivenessof the
jaw thrust or chin lift maneuvers'
r To provide neutral alignment of the cervical spine
and a neutral position for the child's airway, place
padding under the youn$er child's shouldersto
bring the shouldersinto horizontal alignment
with the external auditory meatus'
r Suction the oropharynx with a rigid tonsil suc-
don to removedebris. Vomitus or secretions
t1
should be removed immediately by suctioning the
patient to prevent aspiration. Suctioning or other
interventionsmustbe done in a manner to pre-
vent stimulation of the child's $a$reflex, which
may causesubsequentvomitin$ or aspiration, as
rvell as bradycardia.
r Fo11owpediatric basic life support $uidelines to
relieve ioreign body ainvay obsfructions'n
if the pediatric patient is unable to maintain a
patent airway after proper positionin$:
Insert an appropriate size nasopharyn$ealainvay
if the ped.iatricpatient is consciousand there is
no eviden;e of iaeid tfaAma oi skul1 fracfure'
Insert an oropharlm$eaiairway if the pediatric
patient is unconsciousor doesnot have a $a$
reflex. Pioper positioning of the head and jarv
must be maintainedevenin the presenceof a
patent alrway.
r Preparefor endotrachealintubation'
Breathing
Once a patent airway has been established,assessfor
the followin$.
Assessment
r Level of consciousness
. SpontaneousresPirations
o Rate and depth of resPirations
. Symmetric chest rise and fall
. Skin color (cyanosis,frrst noted in mucous mem-
branes of the mouth, is a late sign of respiratory
compromise)
o Ptesenceand quality of bilateral breath sounds
- Auscultate bilaterally over the ari1la' The chest wall
of infants and youn$ children is thin: breath sounds
may be transmitted from one side to the opposite
side,leadin$ to "equa1breath sounds," even in the
presenceof a Pneumothora,x'
o Ptesenceof indicators of increasedwork of breathing:
- Nasal flarin$
- Substernal,subcostal,intercostal, supraclavicular,or
suprasternalretractions
- Head bobbing
- Expiratory $runttn$
- Accessorymuscle use
o Jugular vein distention (difficult to assessin infants
and young children) and tracheal position
o Paradoxicalrespirations due to a flai1 segment
 .ioft tissue and bony chest rva1lintegriry
r lv{easurement of oxygen safurationbv a pulse oxime-
ter, if readjly available
- < 95 Yoat sealevel is indicative of respiratory
compromise;exceptionsinclude children with
V€ . - uncorrected conjenital heart defects
/::
Interventions
1-
l:
Breathing present and effective
r Position the pediatric patient to facilitate respiratory
effectivenessand comfort; respiratow mechanicsare
better with the pediatric patient in an upright position.
r In the sponraneousl;u breathingpediatricparient,
deliver supplementaloxygen,as indicatedby the pedi-
- Al1 seriously ili or injured patients should have oxy-
gen administeredat the hijhest concentrafionin a
manner the pediatric patient will tolerate'
- Considerusing a nonrebreathermask at a flow rate
sufficient to keep the reservoir bag inflated during
inspiration;usually requires 12 to 15 liters/minute..
Breathing ineffective
o Assist ventilation rvith 100% oxygenvia a bag-mask
devicefor apnea or hypoventilation
- Assesseffectivenessof assistedventilation by
observingchest rise and fall and auscultatinAfor the
presenceof breath sounds.
. Preparefor endotrachealintubation.
- Indications for intubation includen
l Inadequatecentral nervoussystemcontrol ofven_
tilation resulting in apneaor inadequate
respiratoryeffort (e.9.,severeheadinjury with
decreasinglevel of consciousness or pediatric
ComaScalescoreor GlasgowComaScale[GCS]
score< 8).
r Loss of protective airway reflexes
I Functional or anatomic airway obstruction
r Excessivework of breathing leading to fatigue
r Need for high peak inspiratorypressuresor posi-
tive end-expiratory pressuresto maintain
effective alveolar gasexchange
r Permitting paralysis or sedationfor diagnostic Table4-l EstimatingTracltealTubeSize
studieswhile ensuring protection of the airway . Tubesize(mm)= Ageinyears+ 16
and control of ventilation
- Assembleequipment.
I Suction device: tonsil-tipped or large-bore . Usea length-based
catheter and suction catheter to fit into endotra- Reproduced
cheal tr-rbe (2001).
r Bag-maskwith oxygen source
Sheetz
r Styiet,laryngoscopeblade,and handle Philadelphia,
r Endotrachealtubes: three endotracheaitubes(one
tube of the estimatedrequired size and tubes0.5
mm smallerand 0.5 mm larger). Tube sizecan be
esfimatedusing various strategiesfseeTable 41).
r Tape or endotrachealtube holder
r Exhaled CO2 detector (as available)
- Confirm endokacheal tube placement at the time of
insertion and eachtime the chilC is moved.
r Inirial (primary) confirmarion'
r Observechest rise and fall.
o Listen for breath sounds bilaterally in the a-rilla.
Listen over the stomach.In infants and small
children, referred sounds may be heard over the
stomaclr.Any soundsheard oyer the stomach
.r
*te axillary areas. S j nSt,f H Cfti^fT
o Inok for runr.,vaporin thenrbedrti";.;r;]|orr. N,i
r Secondarvconfirrnation involves .untiution or
exhaledCO2 and oxygenation includinf
. Assessmentof exhaledCa2by colorimetric
deviceor continuous capnography (as available)
- In a child with a perfusing rhythm, exhaled
CO2 detectionis the best method for verifica-
tion of tube placement.'
. Assessmentof o,xygensaturationby pulse
oximeter
o Assessmentof changesor improvementof skin
and mucousmembranecolor
- Securethe tube, maintaining the child's head in a
neutral position.
- Documentendotrachealtube size,cuffedyersus
uncuffedtube,and depth by assessing location of
tube at the lip, gum, or tooth line.
r Appropriatedepth of insertion can be estimated
by one of the foliowing formulas.s
Depth of insertion (c-) : internal tube diameter
(in mm) x 3
Or in children > 2 years of age:
Depth of insertion (".rr) : Age in years + 12
)
Selecta tubethatmatches
thediameter
of thechild's
fifthfinoer
resuscitation
tapesuchastheBroselowTM laoe
withpermission
fromBernardo,
L.M.& Lees,
W.E.
Infants
andchildren.
InK.S.Oman, J.Koziot-Mclain,
& L.J.
(Eds.),
Energency nursing (pp.227-231).
secrets
PA:Hanley& Belfus,
Inc.

43
 - Obtain chest radio$raPh' *ttd.I
cannor.b:.
ac@ss
peripheral
the stomachand T,llll 1:
u immediately considered.'
- Insert a $asfrictube to decompress ffiff#ffi .r rt "ria
distention
the risk of aspiration' Gastric Administer a 20 mVk$ fluid bolus
of a warmed
by limitin$ the (i]e', o'g7o norrnal saline or 1ac-
*^y i-p.a. adequateventilation
-ini*ir.
Y 'downwarcl movement of the diaphra$m'
;;il;ftoruoo"
,"i"a ru"g.r's solution), as
indicated by the
intubation pro-
- Administer medications to facilltate pedialric patient's perfu sion stafr-rs'
a severevolune
ceciurcaPordered' .- ln tt . pediatric patient w-ith
are used' a seda- infused-s'ithin 5 to 10
- If neuromuscularblocking agents a.n.;t, ,tte bolus shoulclbe
fluid depletedpedi-
tive must alsobe $iven' minutes; in the less severely
rnustbe availableaithe be infused over 5 to
- Resuscitationequipment uiri. prti."t the boius shoulcl
of neuromuscular 20 minutes'o
U.aria" prior to adminisffation
1 1 . :r frndin$s indicate
blocking agents. - R epeat
a\eyrB! lle D
i*^- -. ol l l s
tr -eassessment
L
^ .. 1
1 ^u^..l ,t tra
-^ ^1^^,.1,1
--
t --
troruscb
-- be
inadeqtlatetissueperfuslon'
-.1
a D ecompress tension pneumothotf J* ": 11.t"T"* imr:T:
""-'-llr .,,
a."".it; air needed'
u s i l L U-rD ' a a rvl q vs' This maybs indicatedltth. #p.;lft ;* rY,**i' P'rfullo1 ;t:::H
pu:t:t *ii
;
patient is in severerespiratory.ditot:t :t^:..
intubated
;"*t * il;i pt*itl thepediatric Tt"d
co11oic1solutl'ons[septic
un,i ,tot improvin$ lvith other
interyentrons' blood (hemorrha$icloss"sj'
(neuro$enicshock)'
shock),or vasopiessors
the illness or
o Initiate dm$ therapy as indicated by
Circulation
assessfor the injury and Perfusion statr-1s'
Once aclequatebreathin$ is established' as indicateclby
. Initiate synchronizedcardioversion'
foi1o.,ving.
dysrhYthmias'
pulserate is less
Assessrnent . Initiate cardiaccompressionttl qt
quality (vol- perfusion is ineffective
o Central and peripheral pulse rate and than 60 beats/minuieand
x stroke volume)
ume/stren$th) lcardiac output : heart rate
the central pulse in the
- Palpatea brachial pulse as ent
infant; palpate a carotid pulse
in children > 1 year D i sabiIity-B rief I'leurologic Assessm
alsobe usedas a
of ug.! ffl. femoral pulse may After the assessment of ainvaS"breathin$' and circulatior-r'
regardlessof a$e' to determinethe
..rllrui pulse in any patient' conduct a brief neurologice-"aluation
pulseswith absentor weak by the pedialric patient's
- The presenceof central degreeof disability,u' 'itotttttd
poor tissueperftision'
p.iplt.ruf pulsesis a sign of levelofconsciousness.Thefinclingsnrtrstbebasedon'the
tempera- 1eve1'
o Skin color (pa1e,mottled, dusky' cyanotic)' p.aiuoi" patient'sa$eand developmental
ture, and moisture
sustainedpres-
. Capillary refi11'Blanch the nailbeclwith Assessment
of conscious-
releasepressure'The o Determine the pediatricpatient'slevei
sure for a f'ew second'sand then to
to its original color ,tr.. by assessin$ the pediatricpatient's response
time it takesfor the nail to return using the A\TU
refil1is 2 verbal and/or painful stimuli
i, tft. refi1l time'' Normal capillary
"upilury environment'
secondso, less in a warrn ambient mnemonic:
refill'.not related to an
Factorsthat may affect capi11ary - A : Ar'vakeand aiert
pedusion, include a cool to verbal stimuli
alteration i,' g*,'.,ut tissue - V : Responsiveon15z
with vascularcom-
ambient temperature and injury - P : Responsiveonly to
painful stimuii
promise.
- Ul : ComPletelYunresPonsive
o Uncontrolled external bleedin$ . In children with chronic neurolo$ic
impairment'
to their normal or
assessresponsivenessin relation
Interventions whlt the tlpical
baseiine status;n'tt tttt care$iver
chilc1 would be'
Cir cttlation : In effectiv e 1eve1of responslvenessfor their
apply- reactivity to light'
o ControLany uncontrolled externalbleedingby . Assesspupil size,shape'equality' and
site(s)'
ing direct pressureover the bleedin$
bore
. Obtain vascular accessby inserting the lar$est Interventions
and initiat- 1evelof con-
catheter that the vesselcan accommodate r If the assessmentindicates a decreased
ing an intravenous infusion as.indicated
by the investigation durin$ the
sciousness'to"tl"tt further
pediatr-icpatient'sillness or 1nJury' secondaryassessment to identifu the cause'
 . Initiate pharmacologic therapy as prescribed. vital signshas not yet been obtained, it should be done
. Considerthe need for endotrachealintubation to now. Recognizingsubtle and significant alterations in
.,
maintain ainvay patency and,/or ensure adequateven- vital signsis an important part of analyzing the assess-
tilation and oxygenation. ment data. The following vital signs should be assessed
It r
in a1lpediatric patients.
t -g
73
Exposureand EnvironmentalControl r Respirations:Assessthe rate, rhvthm, and depth of
'*-
/+- resnireiinns
frl Assessment
-t r Pulse or heart rate: Auscultate an apical pulse as a
F Unciresstfoepecliatricparient to examine;;;;de.
+ baselinerate in infants and younger chjldren and in
-i* an1'underlying injury or additional signs of illness.
:: any critically ill or injured infant, child, or adolescent.
Infants and children have a larger hodfsr:rfaee-a+ea_to
b_odfwershf+atio-andare at a greater risk to rapidly - Comparecenrraland peripherai pulsesbilaterally
losebody heat r,vhenleft exposed.Initiate methodsto for strengthand equality.
nririntaina normothermic stateor wann the patient, if - When evaluatingcentral and peripheral perfusion,
hypothermic.Cold stress in criticallv ill or iniured palpatethe peripheral pulse on an uninjured
infantscan increasemeral:olicdemands,e.xacerbatflthe exlre[ury.
effcerq nFhrmn'jo "nd hlpo$lycemia,and affectrespons- o Blood pressure:lvleasurethe biood pressureby auscul-
es to resuscitativeefforts. tation, palpation,ultrasonic flow meter,or
noninvasiveblood pressuremonitor.
fnterventions - Blood pressurecuff size can affectthe accuracyof
. Providemeasuresto maintain normal bodv temnera_ readings.An appropriateiy sized blood pressurecuff

G
ture or to lvarm the patient. bladder coversone half to fwo thirds of the oedi-
- Warm blankets atric patient's upper arm.
- Orrerheadr,varminglights or other warming device - Auscultate the initial trlood pressurein infants, chil-
- 'Wann, ambient environment, increasing the room dren, and adolescentswith signsof poor perfusion.
temperafureas needed r Noninvasive,automatedblood pressuremonitors
- Whrrn intravenous fluids via fluid warmer when shouldbe used with caution on critically i11or
bolus volumesof intravenousfluids are adminis- injured pediatricpatients.Somemodelsare not
tered. A variety of commercialiy availablefluid accuratefor extremely high or low blood pres-
warmers are specifically designedto warm intra_ sures.Abnormal readings or significant changes
venousfluids. in readingsshould be va-lidatedby auscultation or
. For periialricpatients with fevers,provide anothermanual method.
measuresto
cool the patient (metabolicdemandincreases70o/oto The bloodpressurein a pediatric patient may be
13 % for every degreeCelsius elevation of temperature within normal limits for the pediatric patient's age
abovenonnal; Bokincreasefor eachde{ree despitesignificantfluid,&lood loss;pediatric
Fahrenheit).*Avoid shivering as shiveringnot only patientscan compensatefor greaterthan a 25%
increasesmetabolicand oxygendemandbut also volume lossbefore systolic blood pressuredrops.
lncreasesthe temperafure. Typical systolic pressurein children Z yearsof age
- Removeexcessiveclothing or blankets. or older is'
- Administer antipyreticsper protocol. - Normal Systolic BP (mm Ug) : 90 + (2 x agein
years)
- In the febrile pediatric patient, consider administer_
ing inlravenous fluids at normal body temperanlre. -Ihe lorvestacceptablelimit of systolicpressurein
-t children 2years of ageor older isn
7
& Lowerlimit of Normal systolic Bp (mm Hg) :
5r.contlarv Assessment 70 + (2 x agein years)
r Diastolic blood pressureis 2/3 of the systolic
Full Setof Vital Signs pressure.
Assessment (ulset a2,1, /- - Temperature:Obtain temperaturevia an appropriate^- g
6.P. tozrJltl
route (e.9.,oral, rectal, axillary), consideringthe Ct' . i
Vital signs may be obtained prior ^
to the secondary child's ageald condition. Avoid rectaltemperatures p-at*il
assessment phase,especiallywhen a team of providers in immunocompromisedpatients.Appendix A pro-
li ts stmu.ltaneouslyinvolved Ntct\cu\c
;:i in providing care to a seri_ vides a conversion table of Celsius and Fahrenheit
.: ously il1 or injured pediatric patient.
If a completeset of temperafures.
:.. fnx ltqn 3b"
+)
 Abnormal Vital Si$ns
Normal pediatric vital signs are listed in Table 4-2'
o Factors affecting heart rate and respiratory rate are
. Apply continuous cardiag cardiorespiratory, or pulse
listed in Table 44.
oximeter monitors, as appropriate,based on the pedi-
atric patient's condition . Serial blood pressuremeasurementsare useful in
pressure
r ]Veight in kilo$rams. The pediatric patient's weight in identifying subtle changes'A widening pulse
(systoiic pirrrltr. - diastolic pressure)can occur sec-
i.ilo!t"*t is need.edftjr calculating medication doses
onauty to increasedintracranial pressureand early
andlntavenous fluid amounts. in
septic shock;'a narrorvin$ pulse pressureis seen
- Obtain h measuredwei$ht whenever possible'
early hyPovolemic shock'
- If circumstancesdo not permit a measuredweight'
- Hwotension is definedby ageand can occur sec-
the weight may be estimated;Table ttrS lists strate-
o"iuw ioiignificant fluid or blood losses'sepsis'
gies for estimating pediatric rveights'
and certain medications' Hypotension is a iate si$n
of shock in the PediatricPatient'
- Hypertension is defined asblood pressureat or
loI 3g9--,1
:r ..
Als - -- -*aboveJhe-g5thperqeq-q1g
I I;:5/e fi1r1
4-21rital54;ns
-siqns i,,
ir;vAi i r Temperafure variations that may indicate iiirious
",J^U;A:| Elccitiessuie
A,gE Fa;:
F*sPrralrrrT condirioninclude:
ivlrrtt'i: (nirn
Sysicirc Hgi - Rectaltemperature> 38"C (100'4'F) in infants
Preterm newborn 55-65 120-180 40-60 younger than? or 3 months of a$e
Term newborn 40-60 90-170 52-92 - Rectaltemperature> 40"C (104"F) in infants 3
't month 30-50 110-180 60-1 04 months to 2 years of agewith no localized sign of
110-180 infection
6 months 25'35 b3- | l c
- Rectaltemperature < 36"C (96'8'F)
1 year 20-30 80-160 70-1 18
2 years 20'30 80-130 73-117
111

4 years 20'30 20
80-1 oc-l
^F l/
For EstimatingPedlatric
Table4-3 Strategies
6 years 18'24 /c-lrc 76-l16
\Yeights
8 years 18'22 70-110 1I
76-1
older
weight;
lastmeasured
thechild's children
10years 16-20 70-110 82-122 " nrr,tne.rt.giver
B4-128 mayknowtheirownweight.
12years 16-20 60-110
16-20 60-105 36
85-1 "Usealength-basedresuscitationtape,suchastheBrosel
14years if 35kgor less'
weight
thechild's
tape,to estimate
J.A.(1999).
fromProehl, Secondary ln J' A'
survey' .Forthechild>lyearolage:Weightinkg=(2xageinyears)+
Adapted
(2nded',pp'4-6)'
procedures
nursing
Proehl(Ed.),Emergency . Forthechild< 1 yearof age:Weightin kg=lgeilngn$s + 4
L
PA:WB
Philadelphia, Saunders.

R'ate
Table4-4 FadorsAffecting Heart Rateand ResPiratorY
Rate
ResP'r'ato'Y Decreased Rate
l-leart
HeartRate
lncreased Decrea.sed
Fate
andRespiratorY
(late)
Hypoxia Vagalstimulation
agitation
Fear,anxietY,
(late)
Hypothermia Hypoxia(late)
Pain
intracranial Hypothermia(late)
Crying Increased Pressure
muscle
Respiratory fatigue Cardiac
PathologY
Fever
Medications Shock(late)
(earlY)
Hypoxia
intracranial
lncreased Pressure
Hypovolemia
Medications
(earlY)
Hypothermia
Shock(early)
Medications

{o
 ,amily Presence o Petechiae,subconjunctival hemorrha$e
o Looseteeth or material in the mouth
The family is the pediatric patient's primary support
system.The ENA recognizesthe role of the family in r Bony deformitiesor angulation
the health and well-being of the patient and supports o Symmelry of facial expressions
allowing families the option of being present for inva- r Jugular vein distention
/ sive and resuscitativeprocedures.t
o Assign a staff member to provide family support and Palpate
I Anterior and posterior fontanels in infants for fu11-
to provide explanationsabout procedures.
r Assessthe needsof the family-taking into considera- ness,bulging.or depression. To providemeaningful
information, fontanels should be palpated while the
tion cultural variances.
child is upright and calm'oand not over obvioustrau-M..6\
. Fecilirateand supportthe femily'sinvolvementin the
ffq hnn-r i-i.r^t
^r
pediatricpatient'scare.
o Trachealposition 'i Q,5d5fl'1
1\qvi'C
o Bony depressions/crepirus
Give Comfortl\v4easu
res
Initiate comfort rneast-lresbasedon the pediarric Eyes/Ears/Nose
patient'schief cornplaint and obviousinjury
Inspect
Examplesare listed in Table 4-5.
. Eye and eyelidposirion.ear position
- Color of scleraand conjunctiva. Observefor sub-
Head-to-ToeAssess
ment
conjunctivalhemorrhage.
Information from the head-to-toeassessment is collect- - Hyphema
ed through inspection,palpation, and auscultation.The
- Ptosis
order anC t-vpeof information collectedin the second-
o Drainageor bleeding
ary assessment n'i11vary basedon the pediatric
patient's develoamental1eve1,chief cornplaint,and o Lacerations,abrasions,or ederna
clinical appearance. o Ecch),mosisor bruising
- Periorbitalecchymosisor raccoon'seyes[suggestive
General Appearance of anterior basilar skuii fiacture)
The generalappearanceof the pediatricpatient can - Postarticularecchymosisor Battle'ssign, which is
assistthe nurse in discerningproblemsthat need fur- bieedinginto the tissuebehind the ears (suggestive
iirer investigation.T'he pediatric patient'sactivity level, of posterior basiiar sku11fracture)
inieractionwith the environment,ouftvardappearance o E1'eglasses or contactlenses
[clean1iness, appropriatenessof clothingfor the season, . Pupils, including size, shape,equality, reactiviqzto
generalnutritional status),and reactionsto caregivers qn,l
l i oht
are important factors in the overallassessment of the ^nc ,- i fr /
r Extraoculareyemovements
child. Bociyposition and alignment, guarding or seif-
protectivemovements,muscletone,and unusual odors, - Observethe child's ability to follow your finger in
suchas gasoline,chemicals,urine, and feces,may be all slx directions.
identified during the secondaryassessment.
Table4-5 Comfort Measures
EIead/Face/Neck . Evaluatepresence andlevelof pain.Paincanbeassessed
During the secondaryassessment a more completeneu- usingself-report,
behavioral or physiologic
observation, meas-
rologicassessment is performed. ures,depending ontheageof thechildandhisorher
r A Pediatric Coma Scalescoreor GCSmay be deter- communication capabilities.n
mined at this time (seeTable 4-6). . Stabilize
suspected fractures
o Determine orientation to person,place,and time in . Applycoldto injurysites
I older children or the ability to rccognrzecaregiversin . Dressopenwounds
' Preverbaland young children. . Provide
a wheelchairor stretcher bypediatric
as indicated
: patient's
conditionandchiefcomplaint
l:
Inspect
; . Considernonpharmacologic developmentally-appropriate
;: ' Lacerations,abrasions,ecchymosis,rashes,asymme-
try or edema techniques pain
to reduce

47
'
ofanobject
tracking
- oo..*etheinfantortoddler's H.,rH l:::.:i?;:i::'1T1::ffi'*ffi::;..,,
in all slr directions'
surgi-
patpate . ::::?"- healed chest tube sites, cenhal lines,
. . periorbitai tendernessor
pain cal incisions, or penetratin$ wounds
o Auricle tenderfresi or pain Attscultate
ante-
. Nasal,tendernessor pain . Equaliry of breath soulds (listening over lateral'
;;;# if possible'posterior lung fields)
Chest and
. Adventitious sound.ssuch as wheezes,crackles,
Insaect friction rubs
. Respiratory rate, depth, work of brealtring, u,se!f , *.'l\ Heart sound.sfor rate, rh1'thm,
and adventirious
muscles, abdominat muscles,paradoxical and friction rub
.orrrrd, such as munnurs, $al1ops,
"...r.ory
chest wall movement
" ' oqy:L:-
. syjmmetryof chestwall movementl "- -,,
-,^rr *,r^*."o-
:;:;;;;^;;;;"".,contusions,1esions/rashes''chestwalltenderness
.jLl:-l'1..:ii:X.:Jli;:::::::.::-"tr:":'m.H::;;HJ'trffi
.rabje -l-5 Pediatric Coma Sca/e"

< 1 year
Score > 1 year
SpontaneoustY
A SpontaneoustY
- Toshout
Toverbalcommand
Topain
/. Topain
NoresPonse
1 NoresPonse

< 1 year
Score > 1 year
Spontaneous
Obeys
Localizes
Pain
Localizes
Pain Flexion-withdrawal
A Flexion-withdrawal
T
Flexion-abnormal
Flexion'abnormat rigiditY)
(decorticate
rigiditY)
(decorticate
Extension
z Extension rigiditY)
(decerebrate
rigiditY)
(decerebrate
NoresPonse
1 NoresPonse
FesPcnse
EesiVer'Dai
5
2 to Years 0 to 23months
Score > 5 years andcoosaPProPriatelY
words/Phrases
ApproPriate Smiles
andconverses
Oriented
words Cries andisconsolable
andconverses
Disoriented lnapproPriate
A
crYing
inaPProPriate
Persistent,
words Persistent screams
criesand/or
lnapproPriate and/or screaming
Grunts, andrestless
agitated,
sounds
Incomprehensible Grunts
z
NoresPonse NoresPonse
1 NoresPonse
ToTAL=3to15
*Scoreisthesumoftheindividua|scoresfromeyeffingjestWbd',,o@f:]jll'.ii?]l
and
inlurv, score
GCS severe
o{<8indicates
head
moderate
indicates
;:'J:Hjil::HilHfflu,fii:;,*;jil,'n6r'i.0,,. ore-12
headiniurY. toambu
a p.Ror.n(Eds.),
Emerg A guide
encypediatrics:
p.T-(1999)-
trompons, p! ***
withpermission
Reprinted
M0:
Louis'
ed.,pp.412'425)'St' Mosby' -"*r-n
ta@ cars(Sth
 . Crepitus Palpate
r Subcutaneousemphysema . Skin temperature (with injuries, compare injured
r Bony deformities extremity to uninjured limb)
o Symmetry and quality of distal pulses.Comparebilat-
*
Abdomen eral peripheral pulsesfor sh"engthand equality.
o Bony crepitus
sl
+'
Inspect
. Use of abdominaimusciesfor breathing o lvlusciesffength and rangeof morion
f'
a,
. Lacerations,abrasions,contusions,rashes,impaled o Sensation
+
f. objects,or ecchymosis
Inspect Posterior Surfaces
. Observefor seatbelt marks in children involvedin
motor vehicle crashes. Inspect
r Distention . Bleeding,abrasions,rvounds,hematomas,or ecchy-
. Feedin€tubesor buttons mosis
c Penetratingwounds or scars from healed surgicai I K.1SneS.
petecnlae,eoema.or purpurt
1ncls10ns o Pafternedinjuries or injuries in various stagesofheal-
ing (suggestiveof child maltreatment)
Attscultate
. Bowel soundsin all quadrants.{ Palpate
r Tendernessand deformity of the spine
Palpate
r Costovertebralangle tenderless
. A11four quadrants for rigidity, tenderness,and guard-
ing.In the infant or )oung child who is crying.
evaluation for firmness or rigidity is more difficult. History
Palpating the abdomen on inspiration a1lowsfor pal- The history is obtained from the caregiver of the infant
pation when the abdcminal muscles are more rela-xed. or young child or from both the caregiver and the older
child or adolescent.The history is an important pieceof
Pelvis and Genitalia the initial data that assiststhe health care provider in p{.1c
Inspect anilyztng assessment findings.The MIVT mnemonic'1
. Lacerations,abrasions,rashes,or ederna (i.e.,mechanismof injury injuries sustained,vital signs,/
and treatment) can be usedto elicit a history from pre-
r Drainagefrom the meatusor vagina
hospital providersfor children rvho have sustained
o Scrotalbleedingor edema
trauma. Additional information related to NIIVT is pro-
. Priapism findicativeof pathologiessuch as sicklecell vided in Chapter 77,PediatricTrauma. The SAMPLE
crisis or spinal cord injury) and CIAI4BEDS-mnemonicsmay also be used to elicit
the history. Table 4-7 outlinesthe componentsof
Palpate
SAMPLE, and Table 4-8 describesthe componentsof
. Pelvic stability
CIAMPEDS. The ENA recommendsfollowinp the
o Anai sphinctertone
CIAMPEDSmnemonic.
o Femoralpulses
Additional information. including social and family his-
Extremities tories,may alsobe needed.

Inspect
DiagnosticProcedures
o Angulation, deformity, open wounds with evidenceof
o The necessityof laboratory and radiographic studies
protmding bone fragments,puncture wounds, edema,
ecchymosis,rashes,pu{pura, or petechiae is determined by the pediatric patient's clinical pres-
entation, pattern of injury history, and specific
' Color (wittr injuries, compare injured extremiry to institutional protocols.
uninjured limb)
o The infant and toddler with serious illness or injury
' Abnormal movement should have a blood glucosemeasured(bedsideglu-
. Position
cosetest, serum glucose)becauseof their risk of
o Scarsor venous
accessdevices hypoglycemiawhen physiologically stressed.
o Signs of congenital
, i1
.E anomalies such as.aclub foot,
t:
tength discrepancies,or clubbing of digits
-f
!
+Y