GENERAL APPROACH TO THE PEDIATRIC PATIENT
Children are arguably the most challenging and rewarding patient group that an emergency physician faces. While comprising almost 30% of emergency department (ED) patients, critical illness and injury are present in only approximately 5%. The majority of pediatric emergency visits are not evaluated in pediatric hospitals, but community emergency departments. The ability to discern and aggressively treat critical illness and injuries in some children while simultaneously not overtesting or treating in others is a key skill for the emergency medicine (EM) physician.
The epidemiology of pediatric emergency medicine changes with the clinical setting. In the prehospital environment, the common presenting complaints are trauma, seizures, respiratory distress, and toxicologic emergencies. In the emergency department, the most common complaints are fever, trauma, injury, respiratory distress, vomiting, diarrhea, or upper respiratory tract infection.
Assessment of the pediatric patient in the emergency department requires an age-specific approach. A sensitive, gentle, communicative manner will help facilitate collaboration with the parent and child for a thorough history and physical examination.
Knowledge of the child’s growth and development often is required for the diagnosis, management, and disposition of the pediatric patient. Severity of acute pediatric illness and injury may be difficult to discern. Recognition of anatomic and physiologic differences remind the examiner of large surface area to weight ratio leading to heat loss and trauma to internal organs that may exist with little sign of external injury. Airway differences are important to understand in order to manage respiratory distress and failure. Observational methods of assessment may be more sensitive to illness and injury acuity in children taking into account such variables as quality of cry, reaction to parent stimulation, state variation, skin color, hydration status, and response social overtures such as talking and smiling. Such observations appear to be more predictive of serious illness than anatomic physical examination using standard palpation, percussion, and auscultation techniques.
Assessment and management of the distressed pediatric patient requires appropriately sized equipment. Table 50–1 provides equipment sizes for invasive procedures in children of different age groups.
Table 50–1.Pediatric procedural equipment sizing. |Favorite Table|Download (.pdf) Table 50–1. Pediatric procedural equipment sizing.
|Age ||Weight (kg) ||Endotracheal Tube ||Laryngoscope Blade ||Chest Tube (F) ||Nasogastric Tube (F) ||Foley Catheter (F) ||Femoral IV |
|Premie 32-wk gestation ||2 ||2.5–3.0 ||1 straight ||8 ||5 ||5 ||3 F, 8 cm |
|Newborn ||3 ||3.5 ||1 straight ||10 ||5 ||8 ||3 F, 8 cm |
|1 mo ||4 ||3.5 ||1 straight ||10 ||5 ||8 ||3 F, 8 cm |
|3–5 mo ||6–7 ||3.5 ||1 straight ||10–12 ||5–8 ||8 ||3 F, 8 cm |
|6–11 mo ||8–10 ||3.5–4.0 ||1 straight ||10–12 ||8 ||8–10 ||3 F, 8 cm |
|1 y ||10–11 ||4.0 ||1 straight ||16–20 ||8–10 ||8–10 ||3 F, 8 cm |
|2–3 y ||12–14 ||4.5 ||1.5–2 straight ||20–24...|