Pediatric emergency medicine trisk 0142 0142
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illness and/or injury are not missed. Clinicians must rely on caretaker accounts and
perceptions of the history, and parental concerns must be considered carefully during
care of the child.
Attention to differences in the anatomy and physiology of children as compared to
adults is also critical: among injured children, multisystem trauma is more likely than
in adults, as impact is distributed more widely throughout the body; compensatory
mechanisms to volume loss and/or vasodilatation make hypotension a late finding;
greater surface area relative to body size causes increased heat and insensible fluid
losses.
PRINCIPLES OF CRITICAL ILLNESS AND INJURY IN CHILDREN
The defining principle of critical illness or injury is the presence of an existing or
potential threat to oxygen delivery to meet the demands of the tissues. This is almost
always the final common pathway leading to morbidity and mortality among sick or
injured children. The body’s oxygen delivery system is separated into the respiratory
system (brings oxygen to the arterial blood) and the circulatory system (controls flow
of oxygenated blood to the tissues). Critical illness or injury leads to a global threat to
oxygen delivery to all tissues of the body. By keeping in mind the concept of lifethreatening illnesses compromising oxygen delivery through respiratory, circulatory,
or neurologic failure, clinicians can better evaluate and treat ill children. You will
encounter this theme in the other chapters in this section, including Chapter 8 Airway
, Chapter 9 Cardiopulmonary Resuscitation , and Chapter 10 Shock .
Children with decreased or failed oxygen delivery to the skin, brain, kidneys, and
cardiovascular system exhibit clinical findings commensurate with injury to each of
these organ systems. Manifestations of central nervous system hypoxia include
irritability, confusion, delirium, seizures, and unresponsiveness. Cardiovascular
manifestations of impaired oxygen delivery include tachycardia or bradycardia,
diaphoresis, and hypotension. Cutaneous manifestations include pallor, cyanosis,
mottling, and poor capillary refill. In Chapter 9 Cardiopulmonary Resuscitation ,
Figure 9.2 shows the progression of physical examination findings associated with
inadequate tissue oxygenation for each of these organ systems.
Triage
An organized triage system is a key component of early identification of children with
significant illness or injury. The majority of pediatric EDs use the 5-level Emergency
Severity Index (ESI) Triage system. Children are triaged by an experienced nurse via
rapid evaluation of MS, VS, chief complaint, and the presence or absence of
comorbid high-risk conditions. Children triaged as ESI 1 require immediate
evaluation, often by an organized rapid response or trauma team; those triaged as ESI
2 should be assessed by clinicians within 30 minutes (see Chapter 6 A General
Approach to Triage ). Table 7.1 lists chief complaints, conditions, or characteristics of
