Pediatric Assessment – Spotlight on Vital Signs
It is often said that “pediatrics are not small adults”. This saying rings true especially in regards to pediatric assessment. Many providers appear to be uncomfortable with pediatric patients and their care and subsequently the patient can suffer as a result. A dated, but still relevant study in 1984 among Los Angeles County paramedics found that vital signs are performed on pediatric patients a lower rate that is statistically significant when compared to adult patients. In my own county, I perform the “Critical PCR” reviews and I can confirm that 25 years later, at least anecdotally, this is still the case. The argument is often made amongst prehospital practitioners that pediatric vital signs, particularly blood pressure cannot be measured accurately, though actual research about that claim is never cited. What is known, however, is that pediatric patients are truly not “small adults” and do require a complete assessment.
In a retrospective study published in 1990, researchers looked back at patient care reports for pediatric patients in Los Angeles County during the mid 80’s (1). A trial review of PCRs was performed to determine if there was a difference in the rate of vital signs performed on pediatric and adult patients. Researchers discovered that paramedics did, in fact, perform vital signs on a lower percentage of pediatric patients than on adult patients. Following the trial study, a two part research project was undertaken, reviewing all pediatric PCRs in the county for a three month period and surveying LA County paramedics to determine a cause for the difference between assessment of adult and pediatric patients.
Researchers reviewed PCRs for each pediatric call in LA County for a three month period in 1984, totaling almost 7000. The patient population was divided by age group for further analysis:
- 0 to 6 months
- 7 months to 2 years
- 3 to 6 years
- 7 to 12 years
- 13 to 18 years
Each PCR was analyzed for the frequency of performance of each of the basics vital signs: blood pressure, pulse and respirations. Reviewers also noted if base hospital contact was made during the call and whether the patient had what was determined to be a “major” or “minor” chief complaint. For purposes of the study, “major” complaints included: multiple trauma, head trauma with loss of consciousness, respiratory distress, altered level of consciousness, full arrest, shortness of breath, foreign body airway obstruction, seizure, syncope, ingestion, overdose, chest pain, abdominal pain and near drowning.
In the first part of the study, researchers determined that the greatest indication of whether vital signs were performed was not patient severity but patient age. Responders were less likely to perform vital signs on patients in younger age groups than they were in older groups regardless of the presence of a “major” complaint. Additionally, it was found that responders were more likely to perform vital signs if base hospital contact was made on the call.
The second phase of the study involved sending confidential surveys to registered paramedics in LA county. A total of 619 surveys were completed and analyzed. The researchers found that the factors most greatly influencing the frequency of performance of vital signs on pediatric patients were confidence in treating patients in that age group and education regarding the treatment of pediatrics. Researchers found that responder confidence increased with the age of the patient. Researchers additionally analyzed the demographics of the survey respondents and found that demographics including gender, age and being a parent did not influence confidence when treating pediatrics. Interestingly, the researchers did find that the numbers of runs in a 24 hour period increased confidence more than total years of experience. For instance, a three year paramedic at an extremely busy station was likely to be more confident when treating pediatric patients than a 10 year paramedic at an extremely slow station.
In all, this study was well designed and complete. Many aspects of the patients and responders were analyzed and useful data were able to be gleaned from the process. Unfortunately, not much appears to have changed in the 20 years since the research was published. Frequency of performance of pediatric vital signs continues to be a problem in many EMS systems around the country.
One of the frequently omitted vital signs for pediatric patients is a blood pressure measurement. The argument is often make that blood pressure cannot be effectively measured in pediatric patients, particularly infants. Two studies, one published in 2009 and one in 2008 looked to confirm whether Korotkoff sounds (used to estimate blood pressure during auscultation) could be heard in young patients (2) and what the interrater reliability was for blood pressure taken on pediatric patient during different activity states (3).
The first study, published in 2009, checked for the presence of detectable Korotkoff sounds in patients divided into age groups of:
- < 1 month
- 1 to 12 months
- 13 to 36 months
At least three inflations were performed with a properly sized cuff and the presence of Korotkoff sounds were noted. Additionally, the estimated measurement of blood pressure was compared to invasive monitoring of BP (generally an arterial line). Researchers found that sounds were routinely audible and allowed for reliable estimation of blood pressure in patients from 1 to 36 months of age.
In a study published in 2008, the reliability of multiple providers performing blood pressures on patients ages 1 to 3 was tested. Given that an often cited reason for being unable to perform a blood pressure on a pediatric patient is the level of agitation, the researchers included scoring criteria for activity level with activity ultimately being broken down in “calm” and “not calm”. Analysis showed that interrater variability (the ability for multiple subjects to reach the same findings) was sufficiently small regardless of the activity state of the patient. This means that auscultation of blood pressure is reliable between two caregivers even with agitated patients. A state of agitation did correlate to increased systolic blood pressure and researchers recommended taking at least one reading when the patient was calm.
Vital signs, including a blood pressure, help determine the severity of a patient, particularly when the patient is at risk for hemodynamic compromise as a result of illness or injury. The decreased rates of performance of pediatric vital signs have been known for 25 years, but little has changed in the way of education to affect change. Providers still think that pediatric vital signs are unreliable in all states but particularly when the patient is agitated. Current research shows, however, that reliable blood pressures can be measured from one month of age onward.
As EMS continues to grow, it is incumbent on practitioners to provide their patients with a complete assessment each time patient contact is made. While the Pediatric Advanced Life Support (PALS) curriculum is expanding to include an emphasis on assessment, programs like Pediatric Education for Prehospital Providers (PEPP) have included assessment in the curriculum for some time. Practitioners could consider trading off classes every two years if their agency allows both certifications. Additionally, practitioners may consider working with their EMS agency or employer to host a pediatric assessment day to allow providers to practice vital signs on patients of all ages. Though pediatrics may not be “small adults”, patients in every age group need a complete assessment including a full set of vital signs.
1 – Gausche, Marianne; Henderson, Deborah P; Seidel, James S. “Vital Signs as Part of the Prehospital Assessment of the Pediatric Patient: A Survey of Paramedics.” Annals of Emergency Medicine. 19.2 (1990): 173-8.
2 – Knecht, KR; Seller, JD; Alpert, BS. “Korotkoff sounds in neonates, infants and toddlers.” Am J Cardiol. 103.8 (2009): 1165-7.
3 – Duncan, Andrea F. et. al. “Interrater Reliability and Effect of State on Blood Pressure Measurement in Infants 1 to 3 Years of Age.” Pediatrics: Official Journal of the American Academy of Pediatrics. 122. (2008): 590-4.