It is important for the emergency physician to be capable of managing pediatric emergencies when they present. Children are a unique and significant subset of patients presenting to the emergency department. In 2010 the Center for Disease Control (CDC) database reported a total of 129.8 million emergency department visits in the United States: 25.5 million visits were patients younger than 15 years, and an additional 20.7 million visits were patients between 15 and 24 years. The emergency physician should be prepared to care for pediatric emergencies, whether they present to a children’s hospital, tertiary referral center, or community hospital. Additionally, the presenting child at an adult hospital may develop an airway problem, acute allergic reaction, or other life-threatening event.
What is the best way for the physician to assess a pediatric emergency department patient? The challenges are to simultaneously obtain a history, perform a physical examination, and determine if the child requires an intervention immediately or whether treatment can wait.
Evaluation of a child in the emergency department begins with an assessment of mental status. Children naturally investigate their environment. A child that does not track the examiner could have a visual deficit or other neurologic issue. A child that is sleeping normally at the time of the encounter would be expected to be less attentive when awoken, whereas a somnolent or lethargic child is a potential emergency.
Respiratory function should be assessed in the initial moments when the physician enters the room. Evaluation of respiratory effort, rate, and oxygen saturation should be made. Stridor is an indication of a potentially obstructed airway and should elicit concern. Acquired upper airway obstruction can be systematically evaluated and should be treated accordingly.
Temperature should be measured at the onset of the visit. Infants younger than 2 months are particularly vulnerable because their immunity has not developed fully and transplacental immunity provided by the mother is declining. Preterm infants are at even greater risk. Fever may prompt a sepsis workup.
The emergency physician needs to obtain a history as well, and should be particularly interested in what prompted the current visit, including what caregivers know and suspect. Past medical history will primarily focus on the conditions, workups, or admissions the child has experienced, which may lend important insight to the visit. Immunization status will also be important to determine if the child is at risk for preventable illnesses.
Review of family history is important. Open-ended questions are most helpful and often raise differential diagnostic possibilities. Close family members may have had atypical presentations of common disease processes. For example, the wise physician will pay attention when family states the child’s father had the same symptoms and was later discovered to have appendicitis.
Other sources of information such as emergency medical ...