usual activity, and oral intake. In particular, abnormal birth histories and immunization records

can have a significant impact on the differential diagnosis

for pediatric patients.

Normal oral intake for an infant depends on their age

(Table 47-1). Any changes from baseline are important to

discover and address. Solids are not generally initiated until

the infant is approximately 6 months of age. When dehydration is a concern, you should ask about the patient's

activity level, oral intake, number of wet diapers, frequency

of diarrhea or vomiting, and their ability to make tears.

Finally, a mismatch between the history and physical

exam or an injury not explained by the historical mechanism provided should prompt the clinician to consider

abuse as a cause of the patient's complaint(s).

..... Physical Examination

Once the history is obtained, it is time to proceed to a

physical examination of the child. Because many children

are nervous and afraid of strangers, especially in the unfamiliar setting of an ED, a calm, gentle approach to the

child during the examination can help a great deal. Having

the parent hold the child on his or her lap or hug the child

against his or her chest can help to both reassure the child

and immobilize him or her during the exam. If the child

does start to cry, repeated examinations may be necessary

to ensure a thorough and accurate assessment.

As in adult emergency medicine, we use the ABCDE

(airway, breathing, circulation, disability, and exposure)

approach to management with a quick general assessment.

Initial assessment includes obtaining the patient's vital signs,

Table 47-2. Normal vital signs in pediatric patients

based on age.

RR Average HR Systolic BP

Age (breaths/min) (beats/min) (mmHg)

Premature 40-70 1 20-170 55-75

0-3 months 35-55 1 00-150 65-85

3-6 months 30-45 90-120 70-90

6-12 months 25-40 80-120 80-100

1-3 years 20-30 70-1 10 90-105

3-6 years 20-25 65-1 10 95-1 10

6-12 years 1 4-22 60-95 1 00-120

1 2+ years 1 2-18 55-85 110-135

which will help guide your management. Normal vital signs

vary significantly according to patient age (Table 47-2).

For example, the normal pulse in a 6-month-old is about

1 10 bpm, but this rate would be considered highly abnormal

in an adolescent. You should also get an accurate weight on

your pediatric patient, as your treatment and medical decision making will often be based on this weight.

As mentioned previously, children have developmental

and anatomical differences that must be taken into

account during your examination. The pediatric airway

poses some unique challenges as compared with adult

patients. The larynx is more cephalad and anterior, the

tongue is proportionally larger, and the epiglottis is t ilted

and more collapsible, all of which make visualization

potentially harder. In terms of endotracheal tube selection,

the narrowest portion of the pediatric airway is at the level

of the cricoid cartilage, which traditionally meant that a

cuffed tube was unnecessary in patients younger than

8 years. This traditional view is becoming less stringent,

however, and many hospitals now use cuffed endotracheal

tubes in all ages (decreasing air leak and improving ventilation efficiency).

The pediatric skeleton and surrounding ligaments and

tissues are also more flexible and less protective than the

adult. The pediatric head is proportionately larger than in

adults, increasing the relative force of head and neck injuries. In addition, greater white matter content in the brain

increases the risk of injury secondary to axonal shearing

and cerebral edema. Infants also have open fontanelles in

their skull until about 18 months of age. Older children

have open growth plates in their long bones for many years

until they close in late adolescence; these are the weakest

portions of the bone and the most prone to injury. Injury

to the growth plates is commonly classified by the

Salter-Harris scoring system (Figure 47-1). Tenderness at

the growth plate without evidence of fracture is indicative

of a Salter-Harris type 1 fracture and generally should be

splinted for patient comfort, improved healing, and

medicolegal protection for the physician.

CHAPTER 47

Normal Type I Type II

Type Ill Type IV Type V

.A Figure 47·1. Salter-Harris classification. Reprinted with permission from Simon RR, Sherman sc,

and Koenigsknecht SJ. Emergency Orthopedics: The Extremities. 5th ed. New York: McGraw-Hill, 2007.

Infants and children are at increased risk of hypothermia

because of their high surface area to volume ratio. Pediatric

patients are at risk for spinal cord injury without

radiographic abnormalities (SCIWORA), because the

horizontal alignment of vertebral facet joints and more

elastic intervertebral ligaments predispose to subluxation

without bony injury. Finally, children overall are at an

increased risk for injury or disease because they are

unable to communicate, are dependent on their parent(s)

or guardian(s), and (especially when very young) are

immunologically immature. Take seriously a parent's report

of a significant change in behavior of his or her child.

DIAGNOSTIC STUDIES

..... Laboratory

Laboratory testing in children is performed much less

frequently than in adult patients. There are few instances in

which laboratory testing is part of the standard of care in

treating pediatric patients in the ED. These instances

include febrile neonates, diabetic ketoacidosis, sickle cell

crises, altered mental status, and neutropenic patients with

fever. Laboratory testing, generally, should b

ysical Examination

Once the history is obtained, it is time to proceed to a

physical examination of the child. Because many children

are nervous and afraid of strangers, especially in the unfamiliar setting of an ED, a calm, gentle approach to the

child during the examination can help a great deal. Having

the parent hold the child on his or her lap or hug the child

against his or her chest can help to both reassure the child

and immobilize him or her during the exam. If the child

does start to cry, repeated examinations may be necessary

to ensure a thorough and accurate assessment.

As in adult emergency medicine, we use the ABCDE

(airway, breathing, circulation, disability, and exposure)

approach to management with a quick general assessment.

Initial assessment includes obtaining the patient's vital signs,

Table 47-2. Normal vital signs in pediatric patients

based on age.

RR Average HR Systolic BP

Age (breaths/min) (beats/min) (mmHg)

Premature 40-70 1 20-170 55-75

0-3 months 35-55 1 00-150 65-85

3-6 months 30-45 90-120 70-90

6-12 months 25-40 80-120 80-100

1-3 years 20-30 70-1 10 90-105

3-6 years 20-25 65-1 10 95-1 10

6-12 years 1 4-22 60-95 1 00-120

1 2+ years 1 2-18 55-85 110-135

which will help guide your management. Normal vital signs

vary significantly according to patient age (Table 47-2).

For example, the normal pulse in a 6-month-old is about

1 10 bpm, but this rate would be considered highly abnormal

in an adolescent. You should also get an accurate weight on

your pediatric patient, as your treatment and medical decision making will often be based on this weight.

As mentioned previously, children have developmental

and anatomical differences that must be taken into

account during your examination. The pediatric airway

poses some unique challenges as compared with adult

patients. The larynx is more cephalad and anterior, the

tongue is proportionally larger, and the epiglottis is t ilted

and more collapsible, all of which make visualization

potentially harder. In terms of endotracheal tube selection,

the narrowest portion of the pediatric airway is at the level

of the cricoid cartilage, which traditionally meant that a

cuffed tube was unnecessary in patients younger than

8 years.