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Chapter 1: Approach to the Child in the Emergency Department

Valerie McDougall Kestner

High-Yield Facts

  • The emergency physician must have a reasonable knowledge of the developmental stages to identify abnormal or delayed development.

  • Observation of the young child during history taking provides much insight regarding the severity of his affliction.

  • Often, the best examination occurs while the parent is holding the child in her lap or arms.

  • Good history taking can minimize the need for blood work.

  • Minimizing radiation exposure, the “as low as reasonably achievable” (ALARA) principle is particularly important in children.

The approach to children in the emergency department (ED) is completely different than for the adult. The physician gets one attempt to engage the patient, greet the parent, perform the examination, and formulate a treatment plan.

Children present to the ED for various reasons (Table 1-1).1 This chapter focuses on deconstructing the visit and empowering the emergency physician to be comfortable with and competently treat the child.

TABLE 1-1Most Common Diagnoses for Children Presenting to Emergency Department
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TABLE 1-1 Most Common Diagnoses for Children Presenting to Emergency Department

<1 y

1–12 y

13–21 y

Acute upper respiratory infections

Acute upper respiratory infections

Contusion with intact skin surface

Pyrexia of unknown origin

Otitis media and eustachian tube dysfunction

Open wound, excluding head

Otitis media and eustachian tube dysfunction

Open wound of head

Abdominal pain

Unspecified viral and chlamydial infections

Contusion with intact skin surface

Fractures, excluding lower limb

Noninfectious enteritis and colitis

Pyrexia of unknown origin

Acute upper respiratory infection, excluding pharyngitis

Reproduced with permission from Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Advance Data from Vital and Health Statistics; No. 386. Hyattsville, MD: National Center for Health Statistics; 2007. http://www.cdc.gov/nchs/data/ad/ad386.pdf (Table 12).

Knowledge of age-specific biologic variables is absolutely required to identify abnormalities. Tables 1-2 to 1-52–6 provide quick reference for normal pediatric respiratory rate, heart rate, blood pressure, and weight.

TABLE 1-2Normal Respiratory Rates for Children
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TABLE 1-2 Normal Respiratory Rates for Children

Age (y)

Respiratory Rate/min

<1

24–38

1–3

22–30

4–6

20–24

7–9

18–24

10–14

16–22

15–18

14–20

Reproduced with permission from Bardella IJ. Pediatric advanced life support: a review of the AHA recommendations. Am Fam Physician. 1999;60(6):1743–1750.

TABLE 1-3Normal Heart Rates for Children
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TABLE 1-3 Normal Heart Rates for Children

Age (y)

Heart Rate (beats/min)

<1

100–160

1–10

70–120

>10

60–100

Reproduced with permission from A.D.A.M., Inc. Medical Encyclopedia of MedlinePlus 2007. http://www.nlm.nih.gov/medlineplus/ency/article/003399.htm.

TABLE 1-4Normal Blood Pressure for Children
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TABLE 1-4 Normal Blood Pressure for Children

Age

Systolic BP (mm Hg)

0–28 d ...

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