Children are not just small adults. This
standard mantra is heard in EDs around the world. About one third
of all ED visits are by children. The ABCs of resuscitation are
the same as in adults, but nearly every other aspect of the management
of children is fundamentally different from that of adults. Anatomic,
physiologic, and developmental differences of children give rise
to a unique epidemiology, pathophysiology, and differential diagnosis.
Key elements of the medical history must often be elicited from
caretakers, not from the child. It may be difficult to perform a
physical examination on a child, and cardinal signs of disease are
different. Diagnostic testing can cause pain, or even potential
harm. Drugs require weight-based dosing, and equipment selection
must be tailored to the child’s size. Disposition may require
transfer to a specialized children’s hospital. Finally,
even though the child is the primary patient, management must be
family centered and often involves addressing the fears and stresses
of family members.
There are differences in the environments of pediatric and general
EDs. Pediatric EDs treat more children with underlying medical problems
than do general EDs, and general EDs treat more children with injuries.
Children visiting pediatric EDs are usually sicker, they have longer
wait times to see a physician, and their length of stay in the ED
This chapter highlights the unique features of the emergency
care of children. General principles are discussed with specific
examples derived from common complaints. Chapter
e109.1, Assessment of the Child in the Emergency Department: A Practical
Application of Normal Child Development, provides a comprehensive
review of the normal child, including a primer on developmental
stages, family-centered care, and age-specific physiologic norms.
Pediatric age groups are divided into neonates(birth
to 1 month), infants (1 month to 1 year), toddlers (1
to 3 years), school-aged children (3 to 12 years),
and adolescents (12 to 18 years). Significant anatomic
and physiologic changes occur across these age groups.
Neonates undergo the most profound changes as they transition
from metabolic and respiratory dependence on the placenta to independence as
air-breathing beings. The cardiovascular and respiratory systems switch
from near complete shunting of blood flow away from the lungs to typical
adult circuitry and dependence on the lungs for oxygenation as the ductus
arteriosus closes (see Chapter 122A, Pediatric
Heart Disease: Congenital Heart Defects). Oxygen-avid fetal
hemoglobin changes to adult hemoglobin with predictable changes
in hemoglobin levels throughout the first years of life. The neonatal
and infant immune systems depend on passive maternal humoral protection
transferred through the placenta and breast milk until cellular
and humoral defenses mature. Immunologic immaturity predisposes
to bacterial and viral systemic infections early in life. The neurologic
system is characterized by rapid growth, differentiation, and myelinization
and changes in the balance of excitatory and inhibitory neurotransmitters,
which account for susceptibility to seizures.
Anatomically, growth and development of every organ system ...