ANATOMICAL DIFFERENCES IN THE PEDIATRIC PATIENT

BODY PROPORTIONS Head relatively larger than the rest of the body; proportions become adult-like by adolescence PREHOSPITAL CONSIDERATIONS During falls or mechanisms where the child is thrown, the body acts as a missile with the head leading the way; reason for high incidence of head trauma

Greater body surface area to total body weight than adult Additional padding may be necessary under shoulders when maintaining airway or immobilizing the C-spine Able to lose more body heat and water through the surface of the skin; prone to hypothermia and dehydration PREHOSPITAL CONSIDERATIONS

AIRWAY

Tongue larger in comparison to size of Increased potential for airway obstruction the oral cavity Vary technique with opening airway; head should Trachea shorter and narrower; cartilage be in a neutral position with neck slightly is more elastic and collapses easily extended Younger children have a larger proportion of soft tissue in the airways Newborns up to 2-4 months of life are obligate nose breathers Airways smaller and narrower; narrowest part of airway is at the cricoid cartilage, unlike the adult which is at the level of the vocal cords MUSCULOSKELETAL Newborns have two fontanels; the anterior closes between 10 and 16 mos and the posterior closes between birth and 3 mos Thoracic cavity or chest wall is softer and more compliant Susceptible to swelling from edema and inflammation from foreign objects, allergic reactions, bacterial or viral infections May have respiratory distress if nose congested or obstructed with mucous since unable to breath through mouth Prone to obstruction when airways congested with fluid, mucous or secretions PREHOSPITAL CONSIDERATIONS Assessment of the anterior fontanel can indicate dehydration or increased intracranial pressure Rib fractures are uncommon; provides minimal protection to the underlying organs and blood vessels within this cavity. Chest trauma may appear subtle externally but have extremely detrimental internal injury

Weaker abdominal muscles cause appearance of abdomen to be distended; also liver and spleen lower and more anterior, so not Provides minimal protection to the intraas protected by the rib cage abdominal organs; trauma to this area can lead to severe organ damage Children are abdominal or

diaphragmatic breathers until 8 years of age

Avoid any restriction or restraints over abdomen so that child may breathe easily; especially when packaging child for transport

PHYSIOLOGICAL DIFFERENCES
PEDIATRIC DIFFERENCES Metabolic rate higher than adults; they require more energy and consume more oxygen (illness and stress accelerates metabolic rate further) PREHOSPITAL CONSIDERATIONS Prone to hypoxia; provide high oxygen environment for critically ill or injured children

Prone to dehydration when there is increased fluid loss due to diarrhea, vomiting, or conditions that Higher fluid requirements due to higher increase metabolic rate metabolic rates; newborn's total body weight is 70-80% water (adult only 50-60%) With trauma, remember actual blood loss is relative to weight (e.g., 200 ml of blood loss may Total circulating blood volume per unit not affect an adult but can cause shock in a one of body weight greater than an adult by 25%; year old) can be estimated to be 80-90 ml per kg

GOLDEN RULE: Varying your approach to the pediatric patient based on their age is one of the keys to a successful physical assessment. GROWTH & DEVELOPMENT CHARACTERISTICS INFANTS (BIRTH TO 6 MONTHS)
CHARACTERISTICS Less than 2 months: Spend most of their time sleeping or eating APPROACH Relatively easy to assess; EMT or EMT-P can approach without concern that presence may upset child

Between 2 and 6 months: more Doesn't matter if exam done in parent's active; constantly moving (extremities and head) when fully alert arms or not since there is no separation anxiety yet No stranger or separation anxiety yet Exam can proceed "head-to-toe" or "toeto-head" Strong or vigorous cry when healthy Younger ones easily consoled with pacifier and older ones are easily distracted by light or repetitive noise Save things that may scare them for last (i.e., stethoscope)

INFANTS (6 TO 12 MONTHS) CHARACTERISTICS APPROACH Younger ones will demonstrate stranger Can be difficult to assess; better to start anxiety; older ones will display separation with the across the room assessment and obtain anxiety history from a distance, before a hands-on exam so child does not perceive your presence as an immediate threat Despite appearance of alertness and understanding, has no capacity for rational understanding of events Ask caregiver to assist during exam and treatment, only if they are calm and cooperative (e.g. they can hold stethoscope on chest, can hold Older children will mirror behavior they see around them; if care-taker hysterical, oxygen mask, can raise up shirt so you can observe respiratory effort, etc.) the child may act the same way Stay low or at eye level with child; talk in a calm and reassuring manner Have care-taker hold child in lap facing away from you, if possible, during exam TODDLER (1 TO 3 YEARS) CHARACTERISTICS APPROACH The terrible two stage actually begins at about Approach the toddler slowly and keep 1 year and lasts until 3 years physical contact to a minimum until he/she is familiar with you Most toddlers resist logic, and they cannot be reasoned with. Stay low or at eye level with child; talk in a calm and reassuring manner Very mobile, opinionated and may be terrified of strangers Allow toddler to remain with caregiver Very curious and have no sense of danger Use play or distraction to help with assessment; introduce equipment slowly and encourage toddler to hold it Exam should proceed "toe-to-head"

Older toddlers may remember earlier experiences with doctors or nurses and be fearful about being Give him/her limited choices; helps provide examined toddler with a sense of control

Exam should proceed toe-to-head

Ask caregiver to assist during exam and treatment