9.3 Pediatric Treatment Considerations

The Pediatric Assessment Triangle

The redesigned EMR exam integrates pediatric care throughout the test rather than isolating it. A child can appear in a scene-safety, primary-assessment, treatment, or handoff item. The fastest, most exam-relevant tool is the Pediatric Assessment Triangle (PAT) — a from-the-doorway, hands-off impression formed in seconds before you touch the child. It has three legs:

• Appearance — remembered as TICLS: Tone, Interactiveness, Consolability, Look/gaze, and Speech/cry. A limp, uninterested, inconsolable, glassy-eyed child is sick.
• Work of Breathing — abnormal sounds (stridor, wheeze, grunting), retractions, nasal flaring, positioning (tripoding, sniffing).
• Circulation to Skin — pallor, mottling, or cyanosis.

The common error is over-relying on one leg, especially Appearance. Integrate all three: poor Appearance plus increased Work of Breathing points toward respiratory failure; poor Appearance plus poor Circulation points toward shock. The PAT does not replace the hands-on primary assessment — it prioritizes it.

Age-Appropriate Vitals and Communication

Children are not small adults, and adult vital thresholds will mislead you. The smaller the child, the faster the normal rates:

A respiratory rate of 40 is alarming in an adult but normal in a newborn. Blood pressure is a late, unreliable sign in children — by the time it drops, shock is advanced — so the EMR watches mental status, work of breathing, skin signs, and capillary refill instead.

Fear makes assessment harder. A caregiver can supply history, medications, allergies, baseline behavior, and the event timeline, and can keep the child calm — but the caregiver is a source of information, not a reason to skip your own impression. Use a calm voice, observe from a short distance before touching, and let a safe caregiver hold the child when possible.

Treatment, Traps, and Handoff

Pediatric medication support demands caution. If local protocol includes pediatric drugs, dosing is weight- or age-based: the pediatric epinephrine auto-injector delivers 0.15 mg for a child under roughly 66 lb (30 kg) versus the 0.3 mg adult device, and oral glucose still requires an awake child who can swallow. The safe exam answer never guesses a dose, never applies adult assumptions to a small body, and requests advanced resources early when the child is unstable.

The single biggest pediatric trap is interpreting a quiet child as a calm child. A youngster in respiratory distress who was loud and fighting and then becomes quiet and still is often tiring and decompensating, not improving. Reassess; do not be reassured.

The sequence never changes: scene safety, primary assessment (PAT then hands-on), immediate treatment within scope, transport/transfer decision, reassessment, and handoff. Keep the child warm, support airway and breathing within scope, and avoid unnecessary separation from a calm caregiver. At handoff, report age and estimated weight if used locally, the chief complaint, the PAT findings, mental status, breathing status, skin signs, caregiver history, any medication given before arrival with time and amount, interventions, and the trend during your care.

Common Pediatric Emergencies

A handful of pediatric problems recur on the exam, and each has a recognition pattern the EMR must know. Respiratory distress is the most common pediatric emergency and the most common path to pediatric cardiac arrest, because children deteriorate through breathing failure long before the heart stops. Early signs include fast breathing, retractions, nasal flaring, and grunting; late, ominous signs include slowing respirations, a quiet child, and a dropping heart rate. The EMR supports the airway, gives oxygen, assists ventilations with a properly sized BVM when breathing is inadequate, and escalates quickly.

Fever with a possible seizure (febrile seizure) frightens caregivers but is usually brief; the EMR protects the child from injury, keeps the airway clear, does not put anything in the mouth, and watches breathing afterward. Choking in a child who can still cough or cry means a partial obstruction — encourage coughing and do not intervene blindly; a child who cannot cough, cry, or breathe has a complete obstruction needing back blows and chest thrusts in an infant or abdominal thrusts in an older child. Dehydration from vomiting and diarrhea shows as dry lips, fewer wet diapers, sunken eyes, and lethargy.

Across all of these, the unifying EMR principle is the same: trust the Pediatric Assessment Triangle and the age-appropriate vital ranges, treat what you find within scope, never guess a dose, and request advanced help early when a child looks sick.