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 be reserved for

confirming a diagnosis that is already suspected clinically,

or for assisting in the final disposition of the patient.

.... Imaging

In certain cases ( eg, trauma, altered mental status, and

suspected intraabdominal pathology), imaging tests such

as radiographs, ultrasound, computed tomography (CT),

and magnetic resonance imaging (MRI) may be necessary.

Plain radiographs are usually well-tolerated by pediatric

patients, as they are performed very fast and parents can be

close by with lead shielding. CT scans are somewhat less

tolerated, especially in younger children, as the patient is

required to leave his or her parent and lie flat on a

hard surface. This is even more pronounced in MRis for

these same reasons, in addition to the anxiety caused by

claustrophobia and loud noises made by the MRI. Anxiety

with imaging is often treated with short-acting sedatives

and/or pain medications (eg, midazolam, chloral hydrate,

and/or fentanyl).

THE PEDIATRIC PATIENT

Pediatric patient presents to ED

History obtai ned from child and parents

Exami nation performed with attention to patient's

developmental stage

Develop a differential diag nosis with consideration given to

age of patient

Discuss plan with parents and child

Figure 47-2. The pediatric patient diagnostic algorithm.

PROCEDURES

The general approach to procedures in children, j ust as in

the physical exam, is less anxiety-provoking by having the

parent participate as much as possible. Discussing the

procedure ahead of time with the parent(s)-especially

taking the time to mention key points during the procedure

and important actions the parents can take to help make

the procedure more comfortable for their child-can be

very helpful. For example, tell parents to hold the child

close, talk to the child, and help keep him or her still while

using sutures to repair a laceration, and tell parents how

doing so will help the child have a better experience (and

cosmetic outcome).

 

 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.

 

When performing a procedure, attempts should be

made to minimize pain and suffering in children through

the use of anesthetic, sedative, and/or pain medications.

Not only will the patient be happier, but the parents will be

more satisfied with their child's care. Use of topical

anesthetics during laceration repair, suprapubic bladder

tap, lumbar puncture, or intravenous access is recommended. During complex laceration repair or fracture

reduction, consider using procedural sedation. These pro ­

tocols use stronger medications such as ketarnine, midazolam, morphine, or fentanyl. Adequate pain relief can

help reduce anxiety as well.

MEDICAL DECISION MAKING

In most pediatric cases, your history and physical exam

are sufficient to rule out serious pathology. However, if

more ominous diagnoses are suggested by the history and/

or physical, testing should move into laboratory, imaging,

and possibly procedures as necessary (Figure 47-2).

TREATMENT

Once treatment strategies are chosen or narrowed down to

a few alternatives, it is a good time to review the options or

plan with the parent(s). The parents can be very helpful in

supporting the clinician in explaining the plan to the

patient. If multiple alternatives are presented, the parents

can help choose an option most in line with their wishes,

preferences, and/or child's comfort.

Medication dosages and emergency equipment must be

appropriate for the patient's weight. Getting an accurate

weight as part of the initial vital signs can help speed

medication calculations at this stage of the ED visit. If a

directly measured weight is unavailable in an emergent

situation, using a resuscitation tape (previously called

Broselow tape) can be extremely helpful. The red arrow on

the tape is placed at the patient's head and the tape is

extended to his/her feet to measure length. There is an

CHAPTER 47

average weight listed on the tape for this length. It is this

weight that is used for medication dosing, etc. All

medication dosages must be calculated on a milligram per

kilogram basis. All treatment should be performed as

quickly and as gently as possible.

DISPOSITION

� Admission

Indications for admission in pediatric patients include

suspected or confirmed acute surgical diagnoses ( eg,

appendicitis), any medical condition requiring further

monitoring and treatment ( eg, asthma, dehydration with

intractable vomiting), and uncertain diagnoses requiring

further work-up. Also, patients with certain social issues,

including suspected abuse, neglect, and failure to thrive,

should be considered for admission pending social services

consultation.

� Discharge

Stable patients with good social supports and medical

follow-up are appropriate for discharge after medical

conditions have been diagnosed and treatment plans

initiated and/or completed. Chronic conditions and related

complex work-ups in otherwise stable patients can be completed by the patient's primary care provider. Because almost

all pediatric patients have regular primary care providers,

patients will benefit from contact between the emergency

medicine physician and the primary care provider to have

appropriate continuity of care after discharge from the ED.

The treatment of the pediatric patient presents unique

challenges and requires specialized training but is easily

achievable by maintaining good rapport and communica ­

tion and showing patience and empathy. These skills will

decrease the amount of anxiety for the patient and parent,

facilitate care, and improve compliance.

SUGGESTED READING

American Academy of Pediatrics Committee on Pediatric

Emergency Medicine, American College of Emergency

Physicians Pediatric Emergency Medicine Committee, O'Malley

P, Brown K, Mace SE. Patient- and family-centered care and the

role of the emergency physician providing care to a chlld in the

emergency department. Pediatrics. 2006;118:2242-2244.

Corrales 1\Y, Starr M. Assessment of the unwell chlld. Aust Pam

Physician. 201 0;39:270-275.

Goldman, RD, Meckler, GD. Pediatrics: Emergency care of children. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 73 1-733.

Hamrn MP, Osmond M, Curran J, Scott S, Ali S, Hartling L,

 

tations can be frank breech (legs are at the fetal face with

the buttocks presenting), complete breech (the buttocks

are presenting, but the fetal hips and knees are flexed), or

incomplete or footling breech (one leg is the presenting

part). Breech presentation is dangerous because the buttocks and legs do not fully dilate the cervix. The fetal head

can become caught in the birth canal during delivery.

Likewise, the cervical opening is not completely occluded

by the buttocks, so cord prolapse can occur.

DISPOSITION

All mothers should be admitted to a postpartum unit, and

the infant should be admitted to a neonatal nursery.

SUGGESTED READING

Lazebnik N, Lazebnik RS. The role of ultrasound in pregnancyrelated emergencies. Radial Clin North Am. 2004;42:315-327.

Stallard TC, Burns B. Emergency delivery and perimortem

C-section. Emerg Med Clin North Am. 2003;2 1 :679-693.

VanRooyen MJ, Scott JA. Emergency delivery. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Clince DM, Cydulka, RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 20l l, pp. 703-71 1 .

The Pediatric Patient

joseph Walli ne, MD

Katrina R. Wade, MD

Key Points

• Inherent differences exist between pediatric and adult

patients.

• Physicians have to treat both the parent and the child.

INTRODUCTION

Infants, children, and adolescents constitute approximately

a third of all visits to emergency departments (EDs) in the

United States. Of these pediatric visits, more than half are

for urgent/nonemergent problems such as otitis media,

respiratory and gastrointestinal infections (often viral),

asthma, fractures, sprains, soft tissue trauma, and minor

head trauma. The challenge of pediatric emergency

medicine is to prevent mortality or increased morbidity by

catching the few cases that need hospital admission or

emergent intervention and ensuring proper discharge of

less ill patients.

Children are considered minors up to their 1 8th birthday. Although no consent is needed for life-saving interventions, minors require their parent's or guardian's

consent for routine medical care and discharge. An exception to this rule is the emancipated minor. "Emancipated

minor" status allows a person less than 18 years of age to

consent for medical care without parental knowledge, consent, or liability. The exact legal terms of what makes a

minor "emancipated" varies slightly from state to state, but

generally includes one or more of the following: marriage

(including becoming divorced, separated, or widowed),

membership in the armed forces, becoming pregnant or

having children, living separately from parent(s) or

guardian(s), or, finally, demonstrating the ability to manage one's own financial affairs. Of the preceding criteria,

discovering a patient is pregnant is the most common

• The older the chi ld, the more reliable the clinical

impression.

• Disposition can be affected by unique family situations.

situation the authors' have encountered that leads to

emancipated minor status.

Another important legal issue for clinicians working

with children is our role as mandated reporters. We have a

duty to protect vulnerable young patients. If there is

reasonable cause to suspect that a child has been abused,

neglected, or placed in imminent risk of serious harm, we

are obligated to involve government agents such as child

protective services, police, etc.

There are many aspects of clinical pediatric emergency

medicine that differ from adult emergency medicine

practice. Not only must you vary your approach to each

patient based on their anatomic, physiologic, and

developmental status, you also have to establish an effective relationship with the patient and his or her caregiver.

In other words, physicians have to treat both the parent

and the child. We review some of these differences later in

this chapter.

CLINICAL PRESENTATION

..... History

Obtain as much information as possible from the child.

Questions should be direct and stated in terms the child

can understand. Further details and clarifications should

be sought from the parents, guardians, or caregivers. The

younger the child, the greater reliance on history obtained

from the parents, and the more the history may be

1 96

THE PEDIATRIC PATIENT

Table 47-1. Average quantity of feedings based on age.

Age

1-2 weeks

3 weeks-2 months

2-3 months

3-4 months

5-12 months

Volume/Feeding (every 3-4 hrs)

2-3 oz

4-5 oz

5-6 oz

6-7 oz

7-8 oz

influenced by the parent(s)' perception of symptoms.

When taking the history, children can become anxious

when separated from parents. Separate children from

parents only when absolutely necessary ( eg, in the case of

an adolescent patient when a sexual and/or illicit drug

history needs to be obtained) or in a younger patient

when abuse or neglect is suspected. Unusual complaints

such as weight loss, night sweats, headaches, or back pain

in a small child should prompt concern for more indolent

or life-threatening underlying pathology, particularly

malignancy.

Important historical information needed in all

pediatric patients includes birth history, immunizations,

prior medical problems, medications, allergies, develop ­

mental milestones,

  Women who are not able to easily access medical

care are not good candidates for outpatient management.

SUGGESTED READING

American College of Obstetricians and Gynecologists. Committee

on Practice Bulletins-Obstetrics. Diagnosis and management of

preeclampsia and eclampsia. Obstet Gynecol. 2002;99:1 59-167.

Echevarria MA, Kuhn GJ. Emergencies after 20 weeks of preg -

nancy and the postpartum period. I n: Tintinalli JE, Stapczynski

JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 201 1, pp. 695-702.

Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol. 2003;1 02:1 8 1-192.

Sibai BM. Diagnosis, prevention, and management of eclampsia.

Obstet Gynecol. 2005;105:402-4 10.

E mergency Delivery

jessica Sime, MD

Key Points

• Assemble sufficient staff and supplies to care for both

the mother and newborn.

• When vaginal bleeding is present, defe r the pelvic

exami nation until placenta previa has been excluded.

INTRODUCTION

Less than 1% of all deliveries are in the emergency

department (ED) because most women in labor are

quickly triaged to the labor and delivery unit. However, if a

woman is going to precipitously deliver, or the hospital has

no obstetric services, it is up to the emergency physician to

be prepared to deliver the infant.

Moreover, deliveries in the ED are more likely to be

considered high risk. Women who deliver in the ED

more often have had little or no prenatal care, may have

substance abuse problems, do not know they are pregnant,

or have been victims of domestic violence. These women

may have higher frequencies of complications such as

premature rupture of membranes (PROM), preterm labor,

malpresentation, umbilical cord prolapse, placenta previa,

abruptio placentae, or postpartum hemorrhage. The

emergency medicine physician must be prepared to manage

these complications.

CLINICAL PRESENTATION

� History

Past medical, surgical, gestational age, and obstetric history

should be obtained, as well as history of prenatal care. It is

important to inquire about vaginal bleeding during labor.

Scant, mucoid bleeding is usually termed bloody show and

• Util ize bedside ultrasound to check feta l presentation.

• Be prepared for complications such as postpartum hemorrhage, shoulder dystocia, and breech

presentation.

occurs when the cervical mucus plug is expelled. Heavy

vaginal bleeding is a worrisome sign and can represent

placenta previa (painless vaginal bleeding from the placenta covering the cervical os) or abruptio placentae (painful bleeding owing to placental separation from the uterus).

The physician should also determine whether the patient

has had a spontaneous rupture of membranes (SROM).

Clear, blood-tinged, or meconium-stained vaginal fluid

suggests rupture of membranes.

� Physical Examination

As always, vital signs are the first step in examination.

Fetal heart rate can be assessed with handheld Doppler

or with electronic fetal monitoring, if available. The

abdomen should be palpated for tenderness and fundal

height. Gestational age can be estimated if the mother is

unsure. At 20 weeks' gestation, the uterus is at the umbilicus, and it grows approximately 1 em every week until

36 weeks.

Pelvic examination should begin with inspection of

the perineum to determine whether the delivery is imminent (crowning). If the patient reports vaginal bleeding,

examination should be deferred until an ultrasound can be

performed. It is important to identify placenta previa first,

as the bimanual and speculum examination can exacerbate

the bleeding.

1 92

EMERGENCY DELIVERY

The bimanual examination determines the position of

the fetus and readiness of the cervix. Sterile gloves should

be used to prevent infection. A normal cervix is thick, only

open at the entry to fingertip, and is firm to touch.

Gradually the cervix thins; this is termed effacement.

Dilation of the cervix progresses from closed to fully open

(10 em). Station indicates the location of the presenting

part relative to the ischial spines. A presenting part at the

ischial spines is at 0 station. If the presenting part is at the

introitus, it is at + 3 station. Position describes the relationship of the presenting part to the birth canal. Usually the

fetal occiput is anterior.

Speculum examination can help identify spontaneous

rupture of membranes. Pooling vaginal secretions should

be tested with Nitrazine paper to determine pH. A dark

blue color correlates to a pH of 7.0-7.4 and indicates the

presence of amniotic fluid. Normal vaginal secretions have

a pH of 4.5-5.5. Next, the cervical os is inspected. The

examiner should identify whether it is open slightly, has

bulging membranes, a visible fetal head, or other presenting part. If the examiner sees a prolapsed umbilical cord,

he or she should keep a hand in the vagina and elevate the

presenting part to prevent cord compression, while an

assistant contacts obstetric services for an emergency

cesarean section.

DIAGNOSTIC STUDIES

� Laboratory

If a patient is about to deliver, no laboratory studies are

necessary. A complete blood count, type and screen,

prothrombin time/partial thromboplastin time are useful

in the event of postpartum hemorrhage. Rh type should be

sent to determine the need for RhoGAM.

� Imaging

Bedside ultrasound is used to determine the fetal position,