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- Sabrija Cerimovic
The primary focus of this essay will be based upon the unique anatomical and physiological differences between a pediatric patient and an adult one, and how these differences may affect the treatment and/or presentation of a child in a pre-hospital environment. Furthermore, this essay will include and explore how these differences can affect the A-E assessment most importantly the underlying airway and breathing differences.
Although one may think that treating a child is the as treating a grown adult, it is not. They differ in weight, shape, anatomical size and major bodily systems such as cardiovascular and respiratory. Similarly another aspect to consider is that children are often psychologically different to adults in many ways. For example, in interpreting pain; all which play a critical part in providing the best care for the patient. One of the biggest priorities and challenges when it comes to treatment as a paramedic is being able to maintain and control the airway of the individual regardless if its pediatrics or not, due to the anatomical challenges that are more prevalent in pediatric patients. Therefore, it is essential to understand and recognize these differences as they will have a direct impact towards the treatment/management of the patient. Respiratory failure is a frequent cause of cardiac arrest in children, regardless if it’s pre-hospital or not, consequently being able to recognize early respiratory compromise from airway obstruction is critical to prevent respiratory failure thus reducing the chance of cardiac arrest. The goal of airway management is to predict and recognize potential respiratory compromise and to provide support and stabilization of the airway in a timely manner. (Derek, 2007) Young infants/children have a relatively large occiput (back of skull); which when lying supine on a flat surface results in neck flexion and potential airway obstruction. Even a small degree of obstruction can significantly affect the pediatric patient’s oxygenation and ventilation (Seid, 2012). Along with this, neonates naturally breathe through their nose for the first 6 months, thus their narrow nasal passages are easily blocked by secretions or congestion and can be damaged by treatment methods such as a nasogastric tube (Macfarlane). Furthermore, pediatric patients have a smaller internal diameter when it comes to the upper and lower airways which in return predispose children to have a higher airway resistance. An example of this is described by Ponselle’s law where it is explained that if the radius is decreased by half the resistance is increased by sixteen times, this in its self is an example of how delicate the pediatric airway/breathing system is, where mild airway obstruction or even inflammation can present moderate or severe respiratory distress. (Weathers, 2010) Infants are largely reliant on a functional diaphragm for proper ventilation as opposed to the accessory muscles compared to adults which depend more on accessory muscles than infants. Therefore, a non-functional diaphragm often leads to respiratory failure.Additionally, the probability of respiratory difficulties in infants and younger children can be attributed due to infants having a relatively lower percentage of type 1 muscle fibers or slow-twitch skeletal muscle in their intercostal muscles and diaphragm; these fibers are much more unlikely to fatigue. (Santillanes, 2008)
The position of the larynx can play a vital role of visualization of the airway, compared to the larynx of an adult which sits between 6th -7th cervical cerebrate. A young child’s larynx sits higher than an adults around the 2nd–3rd cervical veritable, making intubation much more difficult compared to an adult. (Adewale, 2010)
Breathing differences not only vary between adults and young children but can vary greatly between different age groups of children. This is presented by the following example where the breathing rate for an infant of 1-3 years old can be between 30 to 60 breaths per minute compared to an adolescence teenager who has a breathing rate close to adult’s 12-16 breaths per minute (Anatomical and Physiological Differences in Children, 2012).
Furthermore children have a much higher metabolic rate compared to adults, by body surface area children have much higher oxygen consumption in relation to their body size which can result in rapid hypoxia if respiratory distress is present. Pediatric patients breathing can account for up to 40% of the cardiac output, particularly in stressed conditions (Kache, 2013). Along with this smaller children are also at risk of developing acute hypoglycemia due to their livers being unable to store glycogen and usually have a reduced supply of glucose, coupled with the fact that the metabolic rate is typically higher in children puts the children in a much higher risk of hypoglycemic. Compared to adults and older children, infants produce approximately twice as much carbon dioxide and consume twice the amount of oxygen relative to body weight.(Davey, 2012) In some situations the simplest factors can be over looked if you are not aware of the differences between adults and pediatrics. For example, pediatrics patients can develop hypothermia much easier compared to their adult counterparts due to pediatric bodies having a surface area to volume ratio four times higher than adults and only one and a half times heat production compared to adults. This difference in ratio can leave children much more predisposed to hypothermia. Pediatric patients may have not fully developed the muscular system to deal with this drop in temperature, such as having the ability to shiver or vasoconstriction which is essential to produce muscular heat in such a situation. Furthermore children have smaller amounts of adipose tissue stored which is essential for insulation which results in the core body temperature dropping further.Interesting anatomical difference in children is that the head is comparably larger than the rest of the body and tend to balance out around the type of adolescence; this in return causes an unbalanced weight distribution between the body and the head, which can cause the head to act as a projectile and due to the larger head its prone to head larger head loss (Pediatric Assesment, 2012).
When it comes to the presentation of a pediatric patient in comparison to an adult patient, it is essential to be able to differ between the two. Although more can be said about the anatomical and physiological differences and how these affect further treatment, it is quite clear from a paramedic point of view that just from the airway and breathing aspect that pediatric patients are not like miniature adults.
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Pediatric Assesment. (2012). Retrieved March 30, 2014, from Long Beach Regional Fire Training Center: http://www.lbfdtraining.com/Pages/emt/sectiond/pediatricassessment.html
Adewale, D. L. (2010). Anatomical Considerations of the Paedatircs Airway. Retrieved 4 1, 2014, from Europian Society for PAediatric Anaesthesiolgy: http://www.euroespa.org/klant_uploads/berlinlectures/ANATOMICAL CONSIDERATIONS OF THE PAEDIATRIC AIRWAY.pdf
Davey, A. J. (2012). Ward’s Anaesthetic Equipment. Elsevier.
Derek, S. (2007). Pediatric Critical Care Medicine: Basic Science And Clinical Evidence. Springer.
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Macfarlane, F. (n.d.). Paediatric Anatomy and PHysiology and the Basic of Paediatic Anaesthesia. Retrieved 4 1, 2014, from Anaesthesia UK: http://www.anaesthesiauk.com/documents/paedsphysiol.pdf
Santillanes, G. (2008). Pediatric Airway Managment. Retrieved 4 1, 2014, from Departments of Emergency Medicine and Pediatrics,: http://blog.utp.edu.co/maternoinfantil/files/2010/08/V%C3%ADa-a%C3%A9rea-en-pediatr%C3%ADa.pdf
Seid, T. (2012). Pre–hospital care of pediatric patients with trauma. International Journal of Critical Illness and Injury Science, 1-2.
Weathers, E. (2010). The Anatomy of the Pediactic Airway. Retrieved 4 1, 2014, from Respiratory Care Educational Consulting Service, Inc: http://www.rcecs.com/MyCE/PDFDocs/course/V7110.pdf
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