This traditional view is becoming less stringent,

however, and many hospitals now use cuffed endotracheal

tubes in all ages (decreasing air leak and improving ventilation efficiency).

The pediatric skeleton and surrounding ligaments and

tissues are also more flexible and less protective than the

adult. The pediatric head is proportionately larger than in

adults, increasing the relative force of head and neck injuries. In addition, greater white matter content in the brain

increases the risk of injury secondary to axonal shearing

and cerebral edema. Infants also have open fontanelles in

their skull until about 18 months of age. Older children

have open growth plates in their long bones for many years

until they close in late adolescence; these are the weakest

portions of the bone and the most prone to injury. Injury

to the growth plates is commonly classified by the

Salter-Harris scoring system (Figure 47-1). Tenderness at

the growth plate without evidence of fracture is indicative

of a Salter-Harris type 1 fracture and generally should be

splinted for patient comfort, improved healing, and

medicolegal protection for the physician.

CHAPTER 47

Normal Type I Type II

Type Ill Type IV Type V

.A Figure 47·1. Salter-Harris classification. Reprinted with permission from Simon RR, Sherman sc,

and Koenigsknecht SJ. Emergency Orthopedics: The Extremities. 5th ed. New York: McGraw-Hill, 2007.

Infants and children are at increased risk of hypothermia

because of their high surface area to volume ratio. Pediatric

patients are at risk for spinal cord injury without

radiographic abnormalities (SCIWORA), because the

horizontal alignment of vertebral facet joints and more

elastic intervertebral ligaments predispose to subluxation

without bony injury. Finally, children overall are at an

increased risk for injury or disease because they are

unable to communicate, are dependent on their parent(s)

or guardian(s), and (especially when very young) are

immunologically immature. Take seriously a parent's report

of a significant change in behavior of his or her child.

DIAGNOSTIC STUDIES

..... Laboratory

Laboratory testing in children is performed much less

frequently than in adult patients. There are few instances in

which laboratory testing is part of the standard of care in

treating pediatric patients in the ED. These instances

include febrile neonates, diabetic ketoacidosis, sickle cell

crises, altered mental status, and neutropenic patients with

fever. Laboratory testing, generally, should be reserved for

confirming a diagnosis that is already suspected clinically,

or for assisting in the final disposition of the patient.

.... Imaging

In certain cases ( eg, trauma, altered mental status, and

suspected intraabdominal pathology), imaging tests such

as radiographs, ultrasound, computed tomography (CT),

and magnetic resonance imaging (MRI) may be necessary.

Plain radiographs are usually well-tolerated by pediatric

patients, as they are performed very fast and parents can be

close by with lead shielding. CT scans are somewhat less

tolerated, especially in younger children, as the patient is

required to leave his or her parent and lie flat on a

hard surface. This is even more pronounced in MRis for

these same reasons, in addition to the anxiety caused by

claustrophobia and loud noises made by the MRI. Anxiety

with imaging is often treated with short-acting sedatives

and/or pain medications (eg, midazolam, chloral hydrate,

and/or fentanyl).

THE PEDIATRIC PATIENT

Pediatric patient presents to ED

History obtai ned from child and parents

Exami nation performed with attention to patient's

developmental stage

Develop a differential diag nosis with consideration given to

age of patient

Discuss plan with parents and child

Figure 47-2. The pediatric patient diagnostic algorithm.

PROCEDURES

The general approach to procedures in children, j ust as in

the physical exam, is less anxiety-provoking by having the

parent participate as much as possible. Discussing the

procedure ahead of time with the parent(s)-especially

taking the time to mention key points during the procedure

and important actions the parents can take to help make

the procedure more comfortable for their child-can be

very helpful. For example, tell parents to hold the child

close, talk to the child, and help keep him or her still while

using sutures to repair a laceration, and tell parents how

doing so will help the child have a better experience (and

cosmetic outcome).