Case of the Month
December 2005

6-year-old boy - struck by a car

Dispatch

“Aid 74, Engine 27, Medic 14; 6-year-old male, car versus pedestrian”

En route your crew discusses the following considerations:

• Speed of impact
• Request additional resources - airlift, MSO, battalion chief
• Special equipment - pediatric aid kit, pediatric traction splint

Just prior to your arrival dispatch reports the patient is conscious and crying, struck at a low rate of speed.

Scene Size-up
It is dusk when you arrive at an intersection in a residential part of town. You see the child lying in the road. He is crying and stating his legs hurt. The driver of the vehicle and a bystander are tending to him.

Initial Assessment
The patient is crying vigorously and holding his right leg. His right pant leg is torn and there is a small amount of blood present. His skin is warm and dry with good color. He is attentive as you approach; he seems to be breathing well. You quickly determine that his radial pulse is strong and regular. A major blood sweep finds a small hematoma on the back of his head and a small amount of blood on his right upper pant leg. A rapid trauma survey finds no life-threatening injuries:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Short report to the medics?

Initial Treatment
Utilizing the Pediatric Assessment Triangle you decide that he is NOT SICK. He is attentive to his environment, his breathing is not labored, and he has a strong radial pulse. Head and neck stabilization are immediately taken by one EMT as another EMT further evaluates the area of bleeding. Keeping the patient warm and immobilizing him on a backboard are high priorities.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

The crew quickly immobilizes the patient onto a backboard with a pediatric-size cervical collar. Since he is so small lots of padding is used on the board. The padding allows for further examination, if needed. The EMT on the head reassures the frightened child during the procedures and explains all actions. This helps calm the patient. Once on the backboard the patient is covered with a blanket and moved to a warmed aid car. The rest of his clothes are removed and a detailed neck, head to toe exam is performed. No new injuries are found.

The medic unit arrives and places the child on a heart monitor and confirms the aid crew’s findings. Due to the mechanism of injury, the medic unit decides to transport the child, even though his injuries are not serious and his vital signs stable. Medics consider the use of pain control for the orthopedic injury. The local trauma center is the destination of choice.

Pediatric Trauma
Pediatric trauma can be on of the most harrowing situations encountered by the EMS provider. Children can be difficult to evaluate, and their age and vulnerability makes us particularly empathetic.

Realizing the differences between the adult and the pediatric patient can help you better evaluate and treat a young patient:

1. Children have proportionally bigger heads to their body than adults, so they are more likely to sustain a head injury.
2. Children have proportionally larger surface areas than adults, so they tend to loose heat much more quickly than an adult.
3. Children compensate for blood loss differently than adults. A child will steadily increase their heart rate to maintain a good blood pressure until the entire system collapses very quickly. An adult will start to lose blood pressure earlier and take longer for it to fail completely.
4. Children have more flexible bones than an adult. A broken bone in a child is a strong indicator of a significant impact, and therefore a more severe and extensive injury.

There are additional differences, but these are some of the most important points to keep in mind.

The lesson learned from this case:
The Pediatric Assessment Triangle will help you with your SICK/NOT SICK assessment. This useful tool outlines the important aspects of assessing a pediatric patient. Remember the three sides of the triangle:

• Appearance: How does the child interact with his environment?  Is he/she looking around, or staring? Does the child respond appropriately to the attention of a parent?
• Breathing: Is the breathing labored or easy? Is it too fast or slow? Are there other signs of difficulty breathing? (Retractions, grunting, nasal flaring, sniffing position?)
• Circulation: What does the skin look like? Pink and warm or cool, dusky, mottles, or cyanotic? How quick is capillary refill? Is there a radial pulse?

If any one side of the triangle is ‘broken’ then the child is deemed SICK. It can be used with both trauma and medical patients because it is recognized by emergency department personnel who are versed in pediatric assessment.