Pediatric and Geriatric Care

This section of our NREMT study guide covers the critical differences in anatomy, physiology, assessment, and management for pediatric and geriatric patients.

These two groups represent the extremes of the age spectrum and are considered special populations in EMS.

Their unique characteristics mean that assessment findings can be subtle, conditions can deteriorate rapidly, and a specialized approach is required.

Pediatric Patients: Not Just Small Adults

The single most important principle in pediatric care is that children are not miniature adults. Their anatomy, physiology, and emotional development require a distinct approach to assessment and treatment. Errors often occur when adult standards are applied to a child.

Key Anatomical and Physiological Differences

• Airway and Respiratory System: This is the area of greatest difference and highest risk.
  • Airway is Smaller and Softer: A child’s airway is significantly narrower in diameter (like a drinking straw compared to a garden hose) and is more easily obstructed by swelling, mucus, or foreign bodies. The trachea is more flexible and can be “kinked” or occluded if the head is hyperextended or hyperflexed.
  • Tongue is Proportionally Larger: The tongue takes up a much larger percentage of the oropharynx, making it the most common cause of airway obstruction in an unconscious child.
  • Obligate Nose Breathers: Infants, for the first several months of life, breathe primarily through their noses. Therefore, simple nasal congestion from a cold can cause significant respiratory distress.
  • Larynx is Funnel-Shaped (Cricoid Ring is the Narrowest Point): In children under 8, the cricoid cartilage is the narrowest part of the airway. This anatomical feature makes them more susceptible to inflammatory conditions like croup, which cause swelling in this area.
  • Reliance on Diaphragm: Children are “belly breathers,” meaning their diaphragm does most of the work of breathing. Signs of respiratory distress often include prominent use of abdominal muscles and retractions. Fatigue of these muscles leads to respiratory failure.
• Head and Body:
  • Head is Proportionally Larger: A child’s head is larger and heavier relative to their body, with a weaker neck to support it. This makes them prone to head injuries from falls and can cause the neck to passively flex and obstruct the airway when lying supine. Placing a small towel or pad under the shoulders and torso is often necessary to achieve a neutral, patent airway position.
  • Larger Body Surface Area: Children have a larger body surface area to mass ratio. This means they lose heat much more rapidly and are highly susceptible to hypothermia, even in mild conditions. Keeping a child warm is a critical intervention.
• Cardiovascular System:
  • Reliance on Heart Rate for Compensation: Children have a smaller stroke volume (the amount of blood pumped with each beat). To compensate for shock, they rely almost exclusively on increasing their heart rate. Bradycardia (a slow heart rate) is a grave sign, most often indicating severe hypoxia and impending cardiac arrest.
  • Hypotension is a Late Sign: Children can maintain their blood pressure until they have lost a significant amount of blood volume. When their blood pressure finally drops, they are in a state of decompensated shock and will deteriorate very rapidly. Do not wait for hypotension to treat for shock.

Assessment of the Pediatric Patient

• The Pediatric Assessment Triangle (PAT): This is a rapid, hands-off assessment tool to form a general impression of the child’s condition in the first 30 seconds, even before touching them.
  1. Appearance: Assesses brain function and overall well-being. Look for muscle Tone, Interactivity, Consolability, Look/gaze, and Speech/cry (TICLS mnemonic). A child who is limp, unresponsive, or cannot be comforted is considered very sick.
  2. Work of Breathing: Assesses respiratory effort. Look for abnormal sounds (stridor, wheezing, grunting), abnormal posture (tripod position, head bobbing), retractions (skin pulling in between the ribs), and nasal flaring. The presence of any of these indicates significant respiratory distress.
  3. Circulation to the Skin: Assesses perfusion. Look at the child’s skin color. Pallor (pale skin), mottling (a patchy, marbled appearance), or cyanosis are signs of poor perfusion and shock.
• Assessment Approach: Engage the parent or caregiver first. For toddlers and preschoolers, perform a “toe-to-head” assessment to build rapport and trust before approaching the more sensitive head and face area. Speak calmly and get down to the child’s eye level.
• Vital Signs: Be familiar with the normal ranges for heart rate and respiratory rate, which are significantly faster than an adult’s and decrease with age. Capillary refill (<2 seconds) is a more reliable indicator of perfusion in young children than blood pressure.

Common Pediatric Emergencies

• Respiratory Emergencies: The leading cause of cardiac arrest in children is respiratory failure.
  • Croup (Laryngotracheobronchitis): A viral infection of the upper airway causing swelling around the larynx. Hallmarks are a seal-bark cough, stridor, and low-grade fever, often worse at night.
  • Epiglottitis: A life-threatening bacterial infection causing severe inflammation of the epiglottis. The child will appear very ill and toxic, with a high fever, drooling, stridor, and often in a tripod position. Do not attempt to examine the throat.
• Seizures:
  • Febrile Seizures: Common in children 6 months to 6 years old, caused by a rapid spike in body temperature. The seizure itself is typically a brief tonic-clonic event, and the primary prehospital treatment is passive cooling (e.g., removing excess clothing).
• Dehydration: A common problem, especially with vomiting and diarrhea. Signs include dry lips and gums, sunken eyes, a sunken fontanelle (the soft spot on an infant’s head), and poor skin turgor (skin “tents” when pinched).
• Abuse and Neglect: Always maintain a high index of suspicion. Red flags include injuries in various stages of healing, injuries with unusual patterns (e.g., stocking-glove burns from immersion in hot water), injuries to the genitals or buttocks, or a story that is inconsistent with the injuries. Femoral fractures in non-mobile infants are highly suspicious for abuse.

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Geriatric Patients: The Complexity of Aging

Geriatric patients (generally defined as over 65) present unique challenges due to the inevitable physiological changes of aging, the presence of multiple chronic conditions (comorbidities), and the use of multiple medications (polypharmacy).

Key Physiological Changes of Aging

• Cardiovascular System: Arteries stiffen (arteriosclerosis), leading to hypertension and a wider pulse pressure. The heart’s electrical conduction system can deteriorate, leading to arrhythmias like atrial fibrillation. The heart’s ability to increase its rate and contractility to compensate for shock is diminished.
• Respiratory System: The chest wall becomes stiffer, and respiratory muscles weaken. This decreases the vital capacity and the ability to cough effectively, which significantly increases the risk of pneumonia.
• Neurological System: The brain atrophies (shrinks), leaving more space between the brain and the skull. This puts tension on the bridging veins, making elderly patients highly susceptible to slow, chronic subdural hematomas from even minor falls or head strikes. Sensation, vision, and hearing may be dulled, leading to a diminished perception of pain and a higher risk of injury.
• Musculoskeletal System: Osteoporosis (loss of bone density) makes bones brittle and prone to fractures from minimal trauma. Hip fractures after a fall are extremely common and can be a life-threatening event.
• Skin and Renal Systems: The skin becomes thinner, drier, and less elastic, making it more susceptible to tearing. Kidney function declines, which affects the body’s ability to clear medications and regulate fluid and electrolyte balance.

Assessment of the Geriatric Patient

• The “GEMS” Diamond: A framework to remember the key aspects of a thorough geriatric assessment.
  • Geriatric Patient: Remember that geriatric patients often present atypically. A heart attack may present as confusion, not chest pain.
  • Environmental Assessment: The patient’s home can provide crucial clues. Assess for safety hazards (rugs, poor lighting), food availability, cleanliness, and temperature.
  • Medical Assessment: Be aware that a chief complaint of weakness, dizziness, or altered mental status may be the only sign of a serious underlying medical problem, such as a urinary tract infection (UTI), pneumonia, or a silent myocardial infarction (MI).
  • Social Assessment: Determine if the patient has a social support network (family, friends, home health aides). Are they able to care for themselves? Social isolation is a significant risk factor.
• Assessment Challenges:
  • Atypical Presentation: This is the most critical concept in geriatric care. Do not dismiss vague complaints. Maintain a high index of suspicion for serious conditions presenting with non-specific symptoms.
  • Altered Mental Status: Never assume confusion is “just old age” or dementia. It is a sign of a new, serious underlying condition until proven otherwise.
  • Polypharmacy: The patient may be taking multiple medications from multiple doctors. It is critical to get a complete list of all medications. These can cause a wide range of side effects or mask signs of shock (e.g., beta-blockers prevent the heart rate from increasing).

Common Geriatric Emergencies

• Trauma from Falls: Falls are the leading cause of injury and injury-related death in the elderly. Always have a high index of suspicion for underlying medical causes of the fall (e.g., syncope, stroke, heart attack). Expect potential head injuries (subdural hematoma) and hip fractures.
• Acute Coronary Syndrome (ACS): Often presents atypically without classic chest pain. Look for signs like syncope, unexplained weakness, fatigue, confusion, or difficulty breathing.
• Stroke: The risk of both ischemic and hemorrhagic stroke increases dramatically with age due to hypertension and atrial fibrillation.
• Congestive Heart Failure (CHF) and Pneumonia: These are very common causes of respiratory distress in the elderly. Differentiating between the two can be difficult, as both can present with crackles in the lungs.
• Elder Abuse and Neglect: Be observant for signs of neglect (poor hygiene, malnutrition, unsafe living conditions) or abuse (unexplained bruises, pressure sores, fearful behavior). You are a mandated reporter.