Section 7 - Pediatric Hospital-Based Disaster Triage

Purpose: This section of the toolkit assists hospitals with existing pediatric services and those without them in planning for large-scale disaster triage of pediatric patients. These guidelines are based on the premise that the triage system used for routine emergencies should be used be as closely as possible for catastrophic emergencies as well. A triage system for emergencies should employ multiple levels of triage to ensure that pediatric patients receive the most accurate sorting possible, consistent with available resources and staff. The goal is to implement triage in such a manner that limited pediatric resources are used with optimal efficiency.

Note: For the purposes of this section, the assumption is that a hospital will have planned for and purchased equipment, as well as will have identified the additional staff that will be mobilized to manage its expected surge in pediatric patients. Hospitals, both with and without specialty pediatric resources, must identify in advance which staff will serve as the leaders and members of its pediatric disaster response team. Working with this team, as well as local pediatric emergency care and disaster experts, it should be determined how best to apply existing resources to achieve the best triage system possible.

Section Contents

Introduction:

The unique characteristics of children make them more vulnerable in infectious, natural or manmade disasters. While all children have these vulnerabilities, children with special health care needs may also have specific conditions which can place them at even greater risk.

The vulnerabilities of children to natural or manmade disasters and in infectious situations have been described by the Illinois Emergency Medical Services for Children project:

  • Because their skin is thinner and they have a larger surface-to-mass ratio than adults, children are more vulnerable to agents that act on the skin.
  • Children are particularly vulnerable to aerosolized biological or chemical agents because their respiratory rate is faster and they inhale relatively larger doses of the substance than an adult would in the same time. In addition, because the breathing zone of children is closer to the ground, children are more vulnerable to agents like Sarin and chlorine because these agents are heavier than air and accumulate close to the ground.
  • Children have less fluid reserve than adults have and can become dehydrated faster, so they are more vulnerable to the effects of agents that produce vomiting and/or diarrhea.
  • Infants, toddlers, and young children do not have the motor skills to escape from the area of a chemical, biological or other terrorist incident.
  • Children lack cognitive decision-making skills that would help them to figure out how to flee danger or to follow directions from others.
  • Children have smaller circulating blood volumes than adults so if treatment is not immediate, relatively small amounts of blood/fluid loss can lead to irreversible shock or death.
  • Because children are more sensitive to changes in body temperature, have a faster metabolism, and less blood and fluid reserves, a child's condition can shift from stable to life-threatening very rapidly.

Mass Casualties Involving Children

Children are likely to be among the victims in most mass casualty events. They have a higher likelihood of morbidity or mortality because of their anatomy and physiology. Recent history has proven that children may also be targets of terrorism.1 For these reasons, every hospital should anticipate having pediatric victims appear on their doorstep in the event of disaster and must start planning to address the issue of treating pediatric patients.

A frequently recommended first responder triage system specifically for children, named Jumpstart, derived by Romig in 2002, is based on an adult triage system called START (Simple Triage and Rapid Treatment). This pediatric triage system places an emphasis on assessing and opening up the airway along with providing rescue breaths and pulse checks, recognizing the unique physiology of children in whom respiratory failure, rather than cardiac failure, causes death.2

However, JumpSTART is a triage system designed to be used primarily in the pre-hospital setting to determine priority for transport. Hospital-based disaster triage encompasses more complex issues, and must reflect the hospitals' resources, space allocation, anticipation of numbers of incoming victims, and repeated reassessment of the patients. Additionally, hospital-based triage becomes even more complex if decontamination is required prior to entry into the hospital.1

The core of this new triage system is the application of the clinical, history and physical assessment skills that is used in an emergency department triage on a day-to-day basis by experienced nurses and clinicians. However, the new triage system structures the allocation of treatment/care and staffing to provide "the greatest good for the greatest number."

One priority for hospital-based triage is to maximize care of the critically injured by preventing over-triage, which is defined as an overflow of minimally injured/sick and already treated into the critical care areas or emergency department. Quickly establishing treatment and evaluation areas for these minimally injured away from critical areas in the emergency department needs to be addressed.

Another priority of hospital-based triage is triage accuracy. This depends largely on the experience of the clinical staff performing triage. Clinicians not used to evaluating acutely ill children generally over-triage into more severe categories, thus potentially misallocating resources.3

These guidelines were created to assist both hospitals with existing pediatric services and those without to address these priorities and to plan for large-scale disaster triage of pediatric patients. More importantly, the guidelines represent the best-case scenario. Each institution needs to modify the guidelines to reflect their capacity in terms of physical and staff resources.

Pre-Hospital Triage: Decontamination and EMS triage may or may not be performed in the field for all patients. The majority of patients will bypass EMS and go directly to the closest hospital or to the hospital of their choice. Pre-hospital triage will not be discussed in this section.

Overview of Triage Recommendations4-7

Communication and Documentation:

A disaster-specific triage form and chart should be developed. In addition to a traditional chart system, unconventional ways of communication such as tags or writing pertinent information on skin or clothes should also be considered.

While time-consuming questions and assessments not relevant in a disaster scenario should be removed from the disaster triage form, assessments such as a chronic medical condition, proximity to a disaster scene or exposure to harmful agents are important depending on the type of disaster. Information such as identifiers, guardians, instructions and procedures needs to be communicated.

Quickly identifying unaccompanied minors is important because they require special attention and more staffing resources (e.g., accompaniment, special discharge procedure).

Direct communication of new information, such as the need for decontamination between triage and the command center/ local authority, is important and should be facilitated. Unit leaders in the triage and treatment areas should communicate with each other directly.

Personnel

In the event of a disaster, additional personnel performing triage will be required and should be identified and trained in advance. Pediatric experience results in more accurate triage of infants and children. Pediatric patients may be sicker following a disaster because of their unique physiology and their appearance may be deceiving. Therefore, the triage officers triaging pediatric patients ideally should have pediatric experience.

Visual Inspection Officers can be used for 'first impression' triaging. A sample Job Action Sheet–Visual Inspection Officers is included in this section. If decontamination or isolation is required, more than one Visual Inspection Officer will be required.

Each treatment area within the ED and hospital (See Figure 7.1) should have a unit leader who ensures that patients receive an initial and periodic reassessment and that patient flow is maintained. Communication of unit leaders with each other should address moving up- or downgraded patients between areas and should be direct.

In addition, personnel guiding unaccompanied children through triage are needed. Recorders, who do not have to be medical professionals, should help collect personal information at all points during the triage and initial treatment process.

Pediatric Hospital Triage - A Multi-Tiered Approach:4-7

Each hospital needs to determine criteria for switching to a two-tiered triage algorithm based on their mass casualty incident (MCI) capacity or the need for performing additional screens (biological, chemical, or radiological scenarios). This recommended process incorporates two forms of triage: a rapid visual assessment to identify quickly the sickest patients and then a more detailed triage assessment to redefine. See Figure 7.1 for a graphic representation of these concepts.

Tier 1 Visual Assessment (See Figure 7.1)

The first decision is whether the patient will require decontamination secondary to potential chemical or radiological contamination:

  • YES: Decontamination is required

Visual assessment officers outside the hospital (before decontamination) and inside the hospital (after decontamination) constantly assess the flow of patients, prioritize patients for decontamination and assign them to the appropriate treatment area.

Prioritization of the critically ill "to the front of the line" is vital to move them quickly into the resuscitation areas in the emergency department or designated critical care area. Even infants and children appearing dead should be moved into the hospital for a resuscitation attempt. There should be a rapid visual assessment conducted by an experienced clinician (Visual Inspection Officer #1) for those patients who will need immediate decontamination.

This first assessment determines the priority of decontamination, bringing the more critical patients through the decontamination line first and those less critical later. Patients that do not require decontamination should be sent to the appropriate clinical care area.

Since decontamination is not benign and patients may deteriorate during the process, a repeat second visual assessment should occur after decontamination or immediately inside the hospital. This is useful in confirming the first assessment and directing patients to the triage and treatment areas for a more detailed assessment. The second rapid visual assessment is performed by Visual Inspection Officer #2. This second visual assessment allows the person to be sent to the appropriate clinical care area. It would be helpful to assign a recorder to each Visual Inspection Officer.

  • NO: Decontamination is not necessary

The patient will receive only one visual assessment, and will then be sent to the appropriate clinical care area.

Table 7.1a Color Codes And Respective Acuity Areas for Patient Sorting8
  Critical Unstable Potentially Unstable Stable
Color Triage Red Yellow Green
Clinical Care Area Resuscitation Area Triage Area
or other designated area		 Fast Track
or other designated area

Figure 7.1. Multi-Tiered Adult/Pediatric Triage/ED Patient Flow

Both over-triage and under-triage are expected. Reassessments and up-and down-grading patients at multiple steps during the triage process are key to optimal utilization of ED resources.

Tier 2 Triage (See Figure 7.2)

These more detailed assessments occur inside the hospital treatment areas, triage areas, fast track area, and to some extent in the resuscitation area. Triage will include a more detailed hands-on physical exam and pertinent history taking. The patient's condition will be either reconfirmed, down-triaged to lower level of care or up-triaged to higher level of care. Because children can deteriorate abruptly, it is critical to reassess them repeatedly until care is transferred. The unit leaders for each treatment area will supervise and ensure initial and repeat assessments of all children in all areas.

Figure 7.2. Triage Algorithm

Sample Job Action Sheet

Visual Inspection Officers

Reports to: __________________________________

Location: ___________________________________

There will be two Visual Inspection Offices, one before and one after the decontamination process.

Mission: To provide 'first impression' or visual assessment of pediatric and obstetric patients in the initial (pre-decontamination) triage area and assign patients to one of three triage priorities: RED (Critical/Unstable), YELLOW (Potentially Unstable), or GREEN (Stable).

Immediate (first 2 hours):

  • Initiate a 'hands-off' process to evaluate patients via 'first impression' or visual assessment.
  • Assign patients based on first impressions.
  • Color triage corresponds to the level of acuity of injury.
  • The table below defines the terms used for acuity and their corresponding clinical care areas.

    Table 7.1b - Color Codes and Respective Acuity Areas8
      Critical Unstable Potentially Unstable Stable
    Color Triage Red Yellow Green
    Clinical Care Area Resuscitation Area Triage Area
    or other designated area    		 Fast Track
    or other designated area
  • The level of acuity dictates to which clinical area the patient will proceed or the order in which they go through decontamination.
  • Special Situations:
    1. Patients less than 8 years old: In situations where staff is unfamiliar with patients less than 8 years old and patients do not appear to be in critical condition upon visual assessment, identify these patients as Yellow (potentially Unstable). These patients are sent to Triage, where a more detailed history and physical is obtained.
    2. Patients with special needs: In situations where staff is unfamiliar with patients with special needs and patients do not appear to be in critical condition upon visual assessment, identify these patients as Yellow (Potentially Unstable). These patients are sent to Triage, where a more detailed history and physical is obtained. (See Appendix 7.3.)
    3. Patients with exposures requiring decontamination: There will be two Visual Inspection Officers, one before and one after the decontamination process.
      1. The Visual Inspection Officer 1 (before the decontamination process) decides each patient's priority in which to undergo decontamination, prior to any medical intervention.
      2. After the decontamination, the parties will encounter the Visual Inspection Officer 2 for a second visual assessment. Here patients will be assigned to one of three triage priorities. RED (Critical/Unstable), YELLOW (Potentially Unstable), and GREEN (Stable).

Sample Job Action Sheet

Recorder

Reports to: __________________________________

Location: ___________________________________


There will be a Recorder assigned to each of two Visual Inspection Officers who are posted before and after the decontamination process.

Mission: To document the 'first impression' or visual assessment of pediatric and obstetric patients performed by the Visual Inspection Officers in the initial (pre-decontamination) triage area and assign patients to one of three triage priorities: RED (Critical/Unstable), YELLOW (Potentially Unstable), or GREEN (Stable).

Immediate (first 2 hours) and as assigned:

  • Record results of the 'hands-off' process and document to which triage area a patient is transferred. (Color triage corresponds to the level of acuity of injury or illness.)
  • Ensure accuracy of patient tracking.
  • Document patient assignment and whether accompanied/unaccompanied.
  • Document interfacility transfers (into and from the facility).
  • Document fatalities.
  • Share information with local Emergency Operation Center, public health and law enforcement personnel in coordination with Liaison Officer.
  • Document personnel movement through the triage area.
  • Ensure preservation/continuity of documentation through interface with Patient Registration Unit Leader.

Visual Assessment of Children

Visual assessment of a patient's immediate status is done daily in every emergency department by experienced nurses and physicians who quickly decide who needs emergency treatment and who can go through a longer registration and routine triage. The visual assessment described here uses this same technique for rapid mass casualty sorting. The assessment done prior to decontamination would be done by staff in decontamination gear, making it difficult to physically assess patients or to have meaningful communication with them.

The visual assessment described here is based on the Pediatric Visual Assessment Triangle: Breathing, Circulation, and Appearance. (See Figure 7.3.)9

The core element of primary triage is dependent upon identifying abnormal elements of these three areas. Once an abnormal criterion is identified, the patients are immediately sent to the RED Resuscitation Area, where the patient will receive immediate care.

Figure 7.3 - Pediatric Visual Assessment (Triangle)9

First Impression
Appearance
Body Position
Muscle Tone
Mental Status		 Equilateral Traingle Breathing
Visible Movement
Work of breathing
(normal/increased)
  Circulation
Color		  

Important points to remember:

  • Although the ABC mnemonic tool is very helpful in remembering the key elements of pediatric visual assessment, the order of assessment should be B, C, A (Breathing, then Circulation, then Appearance).
  • With infants and young children, form a visual impression before you approach to begin the hands-on assessment process.
  • Abruptly approaching a young child who is already distressed can increase the child's agitation, potentially exacerbating the child's clinical condition.
  • Maintain a calm, reassuring manner whenever you assess a very young patient.
  • To assess younger children, have a parent hold the child or allow the child to sit on a parent's lap if possible.
  • Encourage the parent to participate in the examination.
  • Consider age-related factors throughout the assessment.
  • Allowing infants to suck on a pacifier or gloved finger can calm them.
  • If at any point during the first impression you identify a significant clinical problem, immediately discontinue your visual assessment, approach the child, and begin the hands-on initial assessment.
  • Do not delay lifesaving interventions to initiate monitoring.
  • Fever may make infants and children irritable or somnolent, which can affect the assessment.

Assessment Criteria

Assessment of Breathing:

The Visual Inspection Officer will form a first impression about a patient's respiratory status (See Table 7.2.)

  • If critical or unstable, the patient will be considered RED and sent to the decontamination area ahead of the line or to the resuscitation area, as appropriate.
  • If potentially unstable after decontamination, the patient will be considered YELLOW and sent to the Triage Area or to the appropriate treatment area after decontamination. Frequent re-evaluation is necessary.
  • If breathing is stable, consider the child GREEN. Continue assessment for circulation and appearance based on Tables 7.3 and 7.4.
Table 7.2 - Assessment for Breathing8
Assessment Critical/Unstable
RED		 Potentially Unstable
YELLOW		 Stable
GREEN
Airway Partial to complete obstruction by secretions or blood Patient with secretions Patent
Work of Breathing Absent or increased work with periods of weakness Normal Normal
Central Skin Color Pallid, mottled, or cyanotic Pink Pink
Inspection Absent to decreased chest movements Normal Normal

Additional Points to Remember:

  • In children, respiratory arrest is the primary cause of cardiac arrest.
  • The critical window between onset of apnea and onset of cardiac arrest in children is very short - no more than a minute or two.
  • A child's airway is narrower at all levels than an adult's. The child's anatomy results in higher airflow resistance, so when further narrowed by edema or secretions, the child experiences greatly increased resistance to airflow.
  • Avoid actions that could agitate or frighten a child who is in respiratory distress.

Assessment of Circulation:

The Visual Inspection Officer will form a first impression about a patient's circulatory status, based on Table 7.3.

  • If critical or unstable, the patient will be considered RED and sent to the decontamination area ahead of the line or to the resuscitation area, as appropriate.
  • If potentially unstable, the patient will be considered YELLOW and sent to the Triage area or other designated area after decontamination.
  • If circulation is stable, then continue assessment for appearance based on Table 7.4.
Table 7.3 - Assessment for Circulation8
Assessment Critical/Unstable
RED		 Potentially Unstable
YELLOW		 Stable
GREEN
Skin Color Pallid, mottled, or cyanotic Normal Normal

Assessment of Appearance/Mental Status:

The Visual Inspection Officer will form a first impression about a patient's appearance and mental status. See Table 7.4 for the TICLS Tool for quick assessment of appearance. Table 7.4a–AVPU Scale can be used to further assess mental status.

  • Assessment of mental status in children is age-dependent.
  • If the patient is critical or unstable, the patient will be considered RED and sent to the Resuscitation Area.
  • If the patient is unresponsive to verbal commands but not acting appropriately, send the patient to YELLOW – Holding and Treatment Area.
  • If the patient is alert, send the patient to Fast Track – GREEN.
Table 7.4 - Appearance (TICLS Tool)10
Appearance: Questions to be answered:
Tone Is there vigorous movement with good muscle tone, or is the child limp?
Interactivity Is the child alert and attentive to surroundings, or apathetic?
Will the child reach for a toy?
Does the child respond to people, objects, and sounds?
Consolability Does comforting the child alleviate agitation and crying?
Look/Gaze Do the child's eyes follow your movement, or is there a vacant gaze?
Speech/Cry Are vocalizations strong, or are they weak, muffled, or hoarse?

Table 7.4a - AVPU Scale10
Assessment Critical/Unstable
RED		 Potentially Unstable
YELLOW		 Stable
GREEN
Patient Response Responsive only to pain or unresponsive Responsive to Verbal Commands Alert


Table 7.5 - First Impression of Pediatric Respiratory Emergencies 9
Assessment Distress Failure Arrest
Mental Status Alert, agitated, or combative Extreme agitation or reduced responsiveness Unresponsive
Muscle tone/body position Normal; may assume tripod position Normal tone or hypotonic Atony
Chest Movement Present Present Absent
Work of breathing Increased Greatly increased with periods of weakness Absent
Skin color Pink or pallid Pallid, mottled, or cyanotic Cyanotic

Additional Points of Assessment:

If the child displays abnormal vital signs or heart rate and respiration rate are values that are consistently above or below normal ranges, send the patient to RED–Resuscitation Area. Factors such as fever and anxiety may cause transient abnormal vital signs. Medical staff discretion is needed for these cases. Send the patient to RED–Resuscitation Area when there is doubt.


Table 7.6 - Average Pediatric Heart Rates by Age*/
Table 7.7 - Average Pediatric Respiratory Rates by Age9
Age (years) Heart Rate *
(beats per minute)		 Respiration Rates
(breaths per minute)
Infant (birth to <1 year) 100 - 160 30 - 60
Toddler ( 1 to <3 years) 90 - 150 24 - 40
Preschooler (3 to <6 years) 80 - 140 22 - 34
School aged (6 to <12 years) 70 - 120 18 - 30
Adolescent (12 to 18 years) 60 - 100 12 - 16
*Pulse rates for a child who is sleeping may be 10 percent less.

Table 7.8 - SAMPLE History9
S – Signs and Symptoms Assessment findings and history
A – Allergies Particularly drug and food allergies
M – Medications Medications the child is currently taking; time and amount of last dose
P – Past Medical Problems Especially chronic medical conditions such as asthma, which may predispose to morbidity/mortality
L – Last food or liquids Ask about last food and drink
E – Events leading to illness or injury This will be of special relevance in a disaster. Specific questions will depend on type of event

Additional Points of Assessment of Children

Breathing

In a child who is able to breathe spontaneously, perform the following detailed assessments:

  • Evaluate work of breathing and breath sounds
    • Inspiratory retractions in the suprasternal, supraclavicular, intercostal, or subcostal areas
    • Inspiratory nasal flaring
    • Head bobbing
  • Listen for stridor, grunting, gurgling
  • Count the respiratory rate for a 30-second period
  • Assess the respiratory depth and pattern
  • Evaluate central color at the lips, tongue, and oral mucosa
  • Inspect for chest trauma
  • Auscultate chest by placing the stethoscope below each axilla in turn and compare breath sounds of right and left lung fields to see if equal
  • Decreased breath sounds
  • Wheezing
  • Crackles
  • Optional: initiate pulse oximetry (this may be time-consuming and is not needed for triage process during disasters)

Circulation

  • Note skin color at the lips and tongue, the palms, or the soles of the feet; abnormal skin color (pallor, mottling, or cyanosis) indicates an urgent condition.
  • Palpate the central pulse. Recommended sites:
    • Newborn: base of umbilical cord.
    • Infants and young children: carotid artery.
  • If central pulse present, evaluate strength; weak pulse can indicate decompensated shock.
  • Count rate for 30 seconds and double this figure for the rate per minute.
  • If child is uncooperative, count the rate by auscultating with the stethoscope over left side of chest between sternum and nipple.
  • Compare peripheral and central pulses; they should be similar. Weak or irregular peripheral pulses indicate either poor peripheral perfusion or exposure to cold ambient temperatures; hot skin may indicate fever, infection, or hyperthermia caused by very warm ambient temperatures.
  • Check capillary refill time; delayed capillary refill (more than 3 seconds) may indicate poor perfusion or exposure to cool ambient temperatures.

Appearance

  • Level of Consciousness: All well children will constantly interact with their environment. Proceed with initial assessment when child is markedly irritable, agitated or has reduced responsiveness.
  • Interaction with Parent: A child will respond to his/her name being called. Proceed with initial assessment when the child has a markedly slow or absent response, inconsolable crying, or failure to recognize a parent.
  • Response to Others: A child will recognize your presence. Proceed with initial assessment when there is no response to your presence.
  • Muscle Tone and Body Position: A child will assume a comfortable position. An infant will have his extremities in a flexed position. There will be equal movement with their limbs. Proceed with initial assessment when there is hypotonia, rigidity, or inability to sit.

Mental Status Assessment

Knowledge of unique developmental factors is important in evaluating for normal mental status in pediatric patients. Some of these are outlined below, but it is recommended to refer to other texts for a more comprehensive review of developmental stages. (See Section 14 – The Psychosocial Needs of Children during a Disaster.)

  • Problems arise whenever the caretaker/parent is not present.
  • A standard Glasow Coma Scale is provided (See Table 7.9.)9,11,12 A modified version of the Glasgow Coma Scale (see Table 7.10)9,11,12 has been adapted for assessing infants and young children who lack the developmental maturity to speak or to respond to commands. The resultant score may be helpful for detecting changes in the child's condition over time, but is not designed to help with immediate management decisions and triage.
Table 7.9 - Standard Glasgow Coma Scale9,11,12
Eye Opening Pts Best Verbal Response Pts Best Motor Response Pts
Spontaneous 4 Oriented 5 Follows commands 6
To verbal stimuli 3 Confused 4 Localizes pain 5
To pain 2 Inappropriate words 3 Withdraws to pain 4
None 1 Incomprehensible sounds 2 Flexion to pain 3
    None 1 Extension to pain 2
        None 1

Table 7.10 - Pediatric Glasgow Coma Scale for Infants and Young Children9,11,12
Eye Opening Pts Best Verbal Response Pts Best Motor Response Pts
Spontaneous 4 Coos, babbles 5 Normal spontaneous movements 6
To speech 3 Irritable, cries 4 Withdraws to touch 5
To pain 2 Cries to pain 3 Withdraws to pain 4
None 1 Moans to pain 2 Abnormal flexion 3
    None 1 Abnormal extension 2
        None 1

Characteristics Unique to Each Age Group

  • Infants (0 to <18 months)
    • Ambulation begins at approximately 1 year old.
    • Easily consolable by caregiver (e.g., smiles and coos with parent).
    • Appropriate reaction to others - stranger anxiety associated with crying is normal.
  • Toddlers (18 months to <3 years)
    • Normal: explores the environment (e.g., looking or walking around).
    • Talking appropriate for development: simple words and short sentences.
  • Preschool (3 years to 6 years)
    • Talking: more prominent and longer sentences; ability for others to understand.
  • School aged (7 years to 12 years)
    • Able to verbalize their needs: HOWEVER, the child may regress to earlier stage of development.

Pain Assessment

Measuring pain in infants and children is difficult. Changes in vital signs (heart rate, breathing rate, and blood pressure), facial expression and behavior are most widely used to rate pain. Regular measurements should be taken and recorded. There are different pain rating scales used for infants and children. One example is illustrated below:

Table 7.11 - Faces Pain Rating Scale13

Chart developed by LF Whaley and DL Wong consisting of six cartoon faces ranging from a smiling face for no pain to a tearful face for worse pain

Brief Review of Anatomic and Physiologic Differences9

There are fundamental anatomic and physiologic differences between children and adults that directly affect:

  • How assessment is performed,
  • How children respond to illness and injury, and
  • How treatment and transportation decisions are made.

Illustrations of the Anatomy of Pediatric Airway and Anatomy of Adult Airway

Pediatric Airway Considerations

  • More anterior than adult (less head tilt to open the airway).
  • Smaller diameter of airway than an adult (easily blocked by secretions or blood).
  • Large tongue in relation to jaw size (likely to cause obstructions when child is unconscious).
  • Infants prefer to breathe through the nose (nasal obstructions can cause respiratory distress).

Airway Assessment: Is the child effectively moving air?

  • Is the child able to speak or cry vigorously?
  • Ask the parent to lift the child's shirt.
  • Look for signs of airway obstruction.
  • Observe movement of the chest or abdomen.

Is there a potential for airway compromise?

Listen for sounds that indicate airway obstruction or excessive secretions.

  • Stridor: A high- or low-pitched sound that occurs when the child breathes in that indicates partial obstruction of the upper airway.
  • Foreign body.
  • Swelling (from disease, poison, etc)

If a Foreign Body Airway Obstruction (FBAO) is suspected:

  • Provide humidified high concentration oxygen by non-breather mask or blow-by oxygen tubing until treatment can be completed.
  • If airway swelling is suspected, keep the child in the position most comfortable for breathing.
  • Call another clinician for assistance.

Breathing Assessment: Is the child breathing adequately? Look for:

  • Movement of chest
    • The chest should move smoothly with no noticeable difference from left to right.
    • The depth and rhythm of chest movement should be regular.
  • Extra effort used to breathe
    • Is the child working hard just to breathe?
    • The extra effort of moving air into the lungs or out of the lungs indicates respiratory distress and eventually can exhaust the child.
  • Blue skin tone.
  • Listen for lung sounds.
  • Count respirations.

If the chest is not rising, begin ventilation with a bag-valve mask and supplemental oxygen.

  • Reassess the airway.
  • Position the head.
  • Unlike the adult, ventilate with just enough pressure to see the chest rise.

Circulation Assessment: Determine if perfusion is sufficient.

  • Compare peripheral and central pulses,
  • Skin temperature, and
  • Skin tones.

Unlike in adults, blood pressure is not a reliable indicator of poor perfusion in children and should not be the determining factor used to decide if the child has hypoperfusion. Blood pressure can be measured in children over three, particularly when the condition is non-urgent and there is no need to expedite transport.

Begin circulation assessment by detecting and stopping active bleeding. Use direct pressure, elevation, and when necessary, the proximal pressure point. Remember that seemingly small blood losses can be significant as a child has a much smaller blood volume than an adult.

References:

1. Amir LD, Aharonson-Daniel L, Peleg K, Waisman Y, Israel Trauma Group. The severity of injury in children resulting from acts against civilian populations. Ann Surg. 2005;241(4):666-670.

2. Romig LE. Pediatric triage. A system to JumpSTART your triage of young patients at MCIs. JEMS. 2002;27(7):52-58, 60-63.

3. Maldonado T, Avner JR. Triage of the pediatric patient in the emergency department: are we all in agreement? Pediatrics. 2004;114(2):356-360.

4. Cronin JG, Wright J. Rapid assessment and initial patient treatment team–a way forward for emergency care. Accid Emerg Nurs. 2005;13(2):87-92.

5. Eitel DR, Travers DA, Rosenau AM, Gilboy N,Wuerz RC. The emergency severity index triage algorithm version 2 is reliable and valid. Acad Emerg Med 2003: 10:1070- 1080.

6. Lovejoy JC. Initial approach to patient management after large-scale disasters. Clin Ped Emerg Med. 2002;3(4):217-223.

7. O'Neill KA, Molczan K. Pediatric triage: a 2-tier, 5-level system in the United States. Pediatr Emerg Care. 2003;19(4):285-290.

8. Sanddal ND, Hansen JD, Rahm NS. CUPS Assessment Table. In: Critical Trauma Care by the Basic EMT. 4th ed. Bozeman, MT: Critical Illness and Trauma Foundation; 1997:48.

9. Foltin GL, Tunik MG, Cooper A, Markenson D, Treiber M, Skomorowsky A, eds. Paramedic TRIPP Version 1.0–Teaching Resource for Instructors in Prehospital Pediatrics. New York, NY: Center for Pediatric Emergency Medicine; 2002.

10. American Academy of Pediatrics. Pediatric Education for Prehospital Professionals (PEPP). 1st ed. Boston, MA: Jones and Bartlett Publishers; 2000:36.

11. Holmes JF, Palchak MJ, MacFarlane T, Kuppermann T. Performance of the pediatric Glasgow Coma Scale in children with blunt head trauma. Acad Emerg Med. 2005;12(9):814-819.

12. James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann. 1986;15(1):16-22.

13, Whaley LF, Wong DL. Nursing Care of Infants and Children. 3rd ed. St. Louis, MO: Mosby; 1987.

14. New York State Department of Health Emergency Medical Services for Children Program. New York State Pediatric Assessment Reference Card. 2007. Available at: http://www.health.state.ny.us/nysdoh/ems/pdf/pediatric_assessment_reference_card.pdf. Accessed February 18, 2010.

15. New York State Department of Health Emergency Medical Services for Children Program. Children with Special Health Care Needs–Prehospital Care Reference Card. 2003. Available at: http://www.nyhealth.gov/nysdoh/ems/pdf/referencecard.pdf. Accessed February 18, 2010.

Appendices