Assessment and Management of the Pediatric Patient
Assessment framework
Start with the Pediatric Assessment Triangle (appearance, work of breathing, circulation to skin) to judge severity from the doorway, then complete a primary survey (airway, breathing, circulation, disability, exposure) and a secondary history and exam. Gather a family-centered history (SAMPLE: symptoms, allergies, medications, past history, last meal, events) and obtain a weight in kilograms. Vital signs and blood-pressure norms are age-specific; hypotension is a late sign, and bradycardia in a child often reflects hypoxia. Use validated pain scales by age and development (FLACC for young or nonverbal children, Wong-Baker faces, numeric rating). Examine from least to most invasive, use distraction and parent presence, and reassess after every intervention.
Traps
Adult vital-sign ranges, a normal blood pressure that falsely reassures in compensated shock, and incorrect cuff size are frequent errors. Do not delegate assessment or teaching. Document objective findings and the response to treatment, not just that the child 'looks better.'
Worked example
For a 26-kg child, maintenance fluids by the 4-2-1 rule: 4 mL/kg/hr for the first 10 kg = 40; 2 mL/kg/hr for the next 10 kg = 20; 1 mL/kg/hr for the remaining 6 kg = 6; total 66 mL/hr. The daily Holliday-Segar method gives 100/50/20 mL/kg/day, or 1,620 mL/day. Rule of thumb: weigh in kilograms, calculate, then verify the pump and the patient.