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Pediatric
Education FOURTH
EDITION
FOR PREHOSPITAL PROFESSIONALS
Editors
Susan Fuchs, MD, FAAP, FACEP
Mike McEvoy, PhD, NRP, RN, CCRN
Janna Patterson, MD, MPH, FAAP, AAP Senior Vice
President, Global Child Health and Life Support
World Headquarters Beena Kamath-Rayne, MD, MPH, FAAP, AAP Vice
Jones & Bartlett Learning President, Global Newborn and Child Health
25 Mall Road Melissa Marx, AAP Manager, Life Support Programs
Burlington, MA 01803 American Academy of Pediatrics Thaddeus Anderson, AAP Manager, Maintenance of
978-443-5000 345 Park Boulevard Competency and Simulation
info@jblearning.com Itasca, IL 60143 Michael Greenier, MPH, AAP Life Support Simulation
www.jblearning.com http://www.PEPPSite.com and Course Specialist
www.psglearning.com http://www.aap.org Karen Kostakis, AAP Life Support Programs Assistant
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Copyright © 2021 by the American Academy of Pediatrics.

All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner.
This material is made available as part of the professional educational programs of the American Academy of Pediatrics. No endorsement
of any product or service should be inferred or is intended. The Academy has made every effort to ensure that contributors to the
Pediatric Education for Prehospital Professionals (PEPP), Fourth Edition materials are knowledgeable authorities in their fields. Readers are
nevertheless advised that the statements and opinions are provided as guidelines and should not be construed as official Academy policy.
The recommendations in this publication or the accompanying resources do not indicate an exclusive course of treatment. Variations
considering individual circumstances, nature of medical oversight, and local protocols may be appropriate. The Academy and the publisher
disclaim any liability or responsibility for the consequences of any actions taken in reliance to these statements or opinions.
There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities
represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios
featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only.
The procedures and protocols in this book are based on the most current recommendations of responsible medical sources. This textbook
is intended solely as a guide to the appropriate procedures to be employed when rendering emergency care to the sick and injured. It is not
intended as a statement of the standards of care required in any particular situation, because circumstances and the patient’s physical condition
can vary widely from one emergency to another. Nor is it intended that this textbook shall in any way advise emergency personnel concerning
legal authority to perform the activities or procedures discussed. Such local determination should be made only with the aid of legal counsel.
23826-6
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Library of Congress Cataloging-in-Publication Data
Names: Fuchs, Susan, editor. | McEvoy, Mike, editor. | Pediatric Education
for Prehospital Professionals (Program) | American Academy of
Pediatrics, issuing body.
Title: Pediatric Education for Prehospital Professionals (PEPP) / editors,
Susan Fuchs, Michael McEvoy ; American Academy of Pediatrics.
Other titles: PEPP
Description: Fourth edition. | Burlington, Massachusetts : Jones & Bartlett
Learning, [2021] | Includes bibliographical references and index.
Identifiers: LCCN 2019053393 | ISBN 9781284194579 (paperback) | ISBN
9781284194593 (ebook)
Subjects: MESH: Emergencies | Infant | Child | Emergency Medical
Services--methods | Emergency Medical Technicians--education |
Pediatrics
Classification: LCC RJ370 | NLM WS 205 | DDC 618.92/0025--dc23
LC record available at https://lccn.loc.gov/2019053393
6048
Printed in the United States of America
25 24 23 22 21 10 9 8 7 6 5 4 3 2 1
9781284238266_FMxx_Final.indd 2 24/08/21 12:19 PM

© Jones & Bartlett Learning. Courtesy of MIEMSS.
Brief Contents
Chapter 1 Pediatric Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 2 Using a Developmental Approach. . . . . . . . . . . . . . . . . . . . . . 31
Chapter 3 Respiratory Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Chapter 4 Shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Chapter 5 Resuscitation and Dysrhythmias. . . . . . . . . . . . . . . . . . . . . . . 93
Chapter 6 Medical Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Chapter 7 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Chapter 8 Toxic Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Chapter 9 Behavioral Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Chapter 10 Children with Special Health Care Needs . . . . . . . . . . . . . . . 193
Chapter 11 Child Maltreatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Chapter 12 Emergency Delivery and Newborn Stabilization. . . . . . . . . 233
Chapter 13 Sudden Unexpected Infant Death and Death of a Child. . . . 259
Chapter 14 Children in Disasters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Chapter 15 Medicolegal and Ethical Considerations. . . . . . . . . . . . . . . . 291
iii
iv Brief Contents
Chapter 16 Transportation Considerations. . . . . . . . . . . . . . . . . . . . . . . . 307

Chapter 17 Making a Difference. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Medication Formulary 445
Glossary 459
Index 473
Contents
PEPP Steering Committee. . . . . . . . . . . . . . . . . . . . . . . . . . x Infants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii Assessment of the Infant. . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Toddlers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Assessment of the Toddler. . . . . . . . . . . . . . . . . . . . . . . . . 40
Chapter 1
Pediatric Assessment . . . . . . . . . . . . . 1 Preschoolers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Assessment of the Preschooler. . . . . . . . . . . . . . . . . . . . . 41
Summary of Assessment Flowchart. . . . . . . . . . . . . . . . . 2 School-Aged Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Scene Size-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Assessment of the School-Aged Child . . . . . . . . . . . . . 42
The Pediatric Assessment Triangle . . . . . . . . . . . . . . . . . . 3 Adolescents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Primary Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Assessment of the Adolescent. . . . . . . . . . . . . . . . . . . . . 43
Primary Assessment: The Transport Decision: Children With Special Health
Stay or Go?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Care Needs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Summary of Primary Assessment . . . . . . . . . . . . . . . . . . 19 Assessment of a CSHCN . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Secondary Assessment: History Taking. . . . . . . . . . . . . 20 Tips for the EMS Provider . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Additional Monitoring Devices. . . . . . . . . . . . . . . . . . . . . 26
Ongoing Reassessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Chapter 3 Respiratory Emergencies. . . . . . . . . 49
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Respiratory Distress and Failure . . . . . . . . . . . . . . . . . . . . 50
Chapter 2
Using a Developmental Prearrival Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Approach . . . . . . . . . . . . . . . . . . . . . . 31 Scene Size-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 General Assessment: The PAT . . . . . . . . . . . . . . . . . . . . . . 51
Pediatric Calls and Response From Family Primary Assessment: The ABCDEs. . . . . . . . . . . . . . . . . . 52
and Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 General Noninvasive Treatment. . . . . . . . . . . . . . . . . . . . 54
Communication With the Child and Family Summary of General and Initial Respiratory
or Caregiver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Assessment and General
Vital Signs Through the Ages. . . . . . . . . . . . . . . . . . . . . . . 33 Noninvasive Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Anatomic Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Specific Treatment for Respiratory Distress . . . . . . . . . 56
Summary of Changes in Vital Signs Summary of Specific Treatment for
and Anatomy Through Childhood . . . . . . . . . . . . . . . 37 Respiratory Distress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
v
vi Contents
Management of Acute Respiratory Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Distress: CPAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Presenting Cardiac Arrest Rhythm
Management of Respiratory Failure. . . . . . . . . . . . . . . . 66 and Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Summary of Management of Summary of Cardiac Arrest. . . . . . . . . . . . . . . . . . . . . . . . 107
Respiratory Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Congenital Heart Disease. . . . . . . . . . . . . . . . . . . . . . . . . 107
Primary Assessment: The Transport Decision— Drowning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Stay or Go?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Additional Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 Chapter 6 Medical Emergencies . . . . . . . . . . . 111
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Chapter 4 Shock. . . . . . . . . . . . . . . . . . . . . . . . . . 75 Medication Dosing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Prearrival Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Assessment and Treatment of the
Scene Size-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Actively Seizing Child. . . . . . . . . . . . . . . . . . . . . . . . . . . 116
General Assessment: The Pediatric Assessment of the Postictal Child . . . . . . . . . . . . . . . . . 119
Assessment Triangle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Summary of Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Primary Assessment: The ABCDEs. . . . . . . . . . . . . . . . . . 77 Altered Mental Status (AMS) . . . . . . . . . . . . . . . . . . . . . . 120
Additional Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Summary of Cardiovascular Assessment . . . . . . . . . . . 80 Hypoglycemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Using the Assessment to Identify Shock. . . . . . . . . . . . 80 Congenital Adrenal Hyperplasia . . . . . . . . . . . . . . . . . . 124
Hypovolemic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Cortisol Deficiency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Distributive Shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Panhypopituitarism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Cardiogenic Shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Summary of Altered Mental Status
Obstructive Shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 and Endocrine Disorders. . . . . . . . . . . . . . . . . . . . . . . . 126
General Noninvasive Treatment of Suspected Fever. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Shock of All Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Summary of Fever. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Specific Treatment of Hypovolemia. . . . . . . . . . . . . . . . 86 Nausea, Vomiting, and Diarrhea
Treatment of Septic Shock. . . . . . . . . . . . . . . . . . . . . . . . . 87 (Gastroenteritis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Specific Treatment of Hypotensive Sepsis and Meningitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
(Decompensated) Distributive Shock . . . . . . . . . . . . 88 Heat-Related Emergencies. . . . . . . . . . . . . . . . . . . . . . . . 130
Treatment of Cardiogenic Shock. . . . . . . . . . . . . . . . . . . 88 Summary of Heat-Related Emergencies. . . . . . . . . . . 131
Primary Assessment: Transport Cold-Related Emergencies. . . . . . . . . . . . . . . . . . . . . . . . 132
Decision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Summary of Cold-Related Emergencies. . . . . . . . . . . 133
Summary of Shock States. . . . . . . . . . . . . . . . . . . . . . . . . . 89 Bites and Stings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Chapter 5 Resuscitation Summary of Bites and Stings. . . . . . . . . . . . . . . . . . . . . . 134
and Dysrhythmias. . . . . . . . . . . . . . . 93
Chapter 7 Trauma . . . . . . . . . . . . . . . . . . . . . . . 137
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Prearrival Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Scene Size-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Fatal Injury Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . 138
General Assessment: The PAT . . . . . . . . . . . . . . . . . . . . . . 94 Unique Anatomic Features of Children:
Effect on Injury Patterns . . . . . . . . . . . . . . . . . . . . . . . . 138
Primary Assessment: The ABCDEs. . . . . . . . . . . . . . . . . . 95
Mechanism of Injury: Effect on Injury
Additional Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . .96 Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Summary of Cardiovascular Assessment . . . . . . . . . . . 96 Assessment of the Injured Child . . . . . . . . . . . . . . . . . . 143
Dysrhythmias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 The General Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . 144
Summary of Dysrhythmias. . . . . . . . . . . . . . . . . . . . . . . . 102 The Primary Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . 145
Contents vii
Summary of Primary Assessment . . . . . . . . . . . . . . . . . 152 Children Assisted by Technology. . . . . . . . . . . . . . . . . . 199

Special Airway Considerations Summary of Children Assisted
in Pediatric Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 by Technology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
The Primary Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . 153 The Medical Home for CSHCN . . . . . . . . . . . . . . . . . . . . 209
Additional Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Additional EMS Considerations for CSHCN . . . . . . . . 209
Summary of Additional Assessment. . . . . . . . . . . . . . . 154
Spinal Motion Restriction Chapter 11 Child Maltreatment . . . . . . . . . . . 213
and Splinting for Transport . . . . . . . . . . . . . . . . . . . . . 154 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Pediatric Burn Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Background, Cost, and Definition . . . . . . . . . . . . . . . . . 213
Summary of Burns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Definition of Child Maltreatment. . . . . . . . . . . . . . . . . . 214
Chapter 8 Toxic Emergencies. . . . . . . . . . . . . . 161 High-Risk Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Duties and Communication by the
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Prehospital Professional. . . . . . . . . . . . . . . . . . . . . . . . . 216
Age-Related Differences. . . . . . . . . . . . . . . . . . . . . . . . . . 161 Communicating With the Child
Summary of Age-Related Differences. . . . . . . . . . . . . 163 and Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Prearrival Preparation and Scene Size-Up. . . . . . . . . . 164 Patient Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Role of the Poison Center. . . . . . . . . . . . . . . . . . . . . . . . . 165 Summary of Duties, Communication,
Assessment of the Child with a Possible and Assessment in Suspected
Toxic Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Maltreatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Summary of Assessment of the Child Legislation, Principles, and Protocols. . . . . . . . . . . . . . 223
With a Possible Toxic Exposure. . . . . . . . . . . . . . . . . . 170 Pediatric Human Trafficking. . . . . . . . . . . . . . . . . . . . . . . 225
Toxicologic Management. . . . . . . . . . . . . . . . . . . . . . . . . 170
Organophosphates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Chapter 12 Emergency Delivery
Summary of Toxicologic Management. . . . . . . . . . . . 174 and Newborn Stabilization . . . . . 233
Medicolegal Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Obstetric Delivery in the Prehospital Setting . . . . . . 234
Chapter 9
Behavioral Emergencies. . . . . . . . . 179 Complications During Pregnancy. . . . . . . . . . . . . . . . . 234
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Triage of a Patient in Labor. . . . . . . . . . . . . . . . . . . . . . . . 236
Common Pediatric Psychiatric Summary of Triage of Patient in Labor. . . . . . . . . . . . . 239
and Behavioral Conditions. . . . . . . . . . . . . . . . . . . . . . 180 Preparation for Delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Suicide Attempt/Intentional Ingestions Performing the Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 242
or Exposures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Summary of Vaginal Delivery. . . . . . . . . . . . . . . . . . . . . 245
Adverse Reactions of Psychiatric Medications . . . . . 186 Immediate Care of the Newborn. . . . . . . . . . . . . . . . . . 246
Assessment and Transport of the Child General Principles of Newborn
with a Behavioral Emergency. . . . . . . . . . . . . . . . . . . 187 Resuscitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Specific Newborn Complications . . . . . . . . . . . . . . . . . 251
Chapter 10 Children with Special Summary of Resuscitation of the Newborn . . . . . . . 254
Health Care Needs. . . . . . . . . . . . . 193 Transport Considerations . . . . . . . . . . . . . . . . . . . . . . . . . 254
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Cognitive and Physical Disabilities . . . . . . . . . . . . . . . . 194
Assessment of CSHCN. . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Chapter 13 Sudden Unexpected Infant
Summary of Assessment of CSHCN . . . . . . . . . . . . . . . 198 Death and Death of a Child . . . . . 259
Transport. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Summary of Transport. . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Definition of SUID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
viii Contents
SUID Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 Child Restraint Systems in Ambulances . . . . . . . . . . . 310

Common Clinical Presentation of SUID. . . . . . . . . . . . 260 Transport Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Actions in Suspected SUID. . . . . . . . . . . . . . . . . . . . . . . . 261 Transport Destination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Summary of SUID. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Multiple Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Definition of Brief Resolved Summary of Transport Mode
Unexplained Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 and Multiple Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Common Clinical Presentation of BRUE . . . . . . . . . . . 264
Actions in Suspected BRUE . . . . . . . . . . . . . . . . . . . . . . . 264 Chapter 17
Making a Difference . . . . . . . . . . . 319
Summary of BRUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Responses to an Infant Death. . . . . . . . . . . . . . . . . . . . . 265 Emergency Medical Services for Children . . . . . . . . . 320
Critical Incident Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Summary of EMSC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Public Health Interface. . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
Chapter 14 Children in Disasters. . . . . . . . . . . 271 Prevention and Injury Control. . . . . . . . . . . . . . . . . . . . . 322
Children in Disasters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 Summary of Prevention and Injury Control. . . . . . . . 325
What Is a Disaster?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 The Medical Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Roles of the Prehospital Professional in Summary of the Medical Home. . . . . . . . . . . . . . . . . . . 326
a Disaster. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Quality and Safety in EMSC . . . . . . . . . . . . . . . . . . . . . . . 326
Pediatric Response Considerations. . . . . . . . . . . . . . . . 274 Data and Information Management . . . . . . . . . . . . . . 328
Vulnerable Pediatric Physiologic Summary of Quality, Safety, Data Collection,
and Psychologic Characteristics and Information Management. . . . . . . . . . . . . . . . . . 329
in Disasters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 Prevention: The Prehospital
Effects of Chemical, Biologic, Radiation, Professional’s Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Nuclear, and Explosive Disasters Summary of Roles in Prevention . . . . . . . . . . . . . . . . . . 331
on Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Call to Action: Advocacy for EMSC . . . . . . . . . . . . . . . . 331
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Chapter 15 Medicolegal and Ethical Procedures��335

Considerations. . . . . . . . . . . . . . . . 291 1 Field Reporting�� 336
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291 2 Length-Based Resuscitation Tapes�� 340
Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291 3 Oxygen Delivery�� 342
Summary of Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 4 Suctioning�� 347
Confidentiality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 5 Airway Adjuncts�� 353
Respect for Cultural or Religious Differences . . . . . . 295 6 Foreign Body Obstruction�� 356
Patient Rights and Advocacy. . . . . . . . . . . . . . . . . . . . . . 296 7 Bronchodilator Therapy�� 360
End-of-Life Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 8 Bag-Mask Ventilation�� 363
Pediatric Policies and Procedures . . . . . . . . . . . . . . . . . 301 9 Pulse Oximetry �� 367
Medical Control for Pediatrics. . . . . . . . . . . . . . . . . . . . . 302 10 Orogastric and Nasogastric
Summary of Rationale for Protocols, Tube Insertion�� 369
Policies, and Procedures . . . . . . . . . . . . . . . . . . . . . . . . 303 11 Endotracheal Intubation�� 373
12 Confirmation of Endotracheal Intubation
Chapter 16 Transportation and End-Tidal Capnography�� 383
Considerations. . . . . . . . . . . . . . . . 307 13 Advanced Airway Techniques�� 389
Pediatric Transport. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 14 Intramuscular Injections �� 398
How to Begin Transport. . . . . . . . . . . . . . . . . . . . . . . . . . . 308 15 Intranasal Medication Administration �� 402
Taking Caregivers in the Ambulance. . . . . . . . . . . . . . 309 16 Intravenous Access �� 405
Contents ix
17 Intraosseous Needle Insertion�� 409 24 Removing and Replacing a

18 Cardiopulmonary Resuscitation�� 415 Tracheostomy Tube�� 437
19 AED and Defibrillation�� 420 25 Tourniquet Application �� 441
20 Endotracheal Tube Drug Instillation�� 425
21 Rectal Administration of Benzodiazepines�� 427 Medication Formulary�� 445
22 Spinal Motion Restriction�� 430 Glossary�� 459
23 Needle Thoracostomy�� 435 Index�� 473
PEPP Steering Committee

Jennifer F. Anders, MD, FAAP Ann Dietrich, MD, FACEP, FAAP
Chair, PEPP Steering Committee Representative – National Association of Emergency
Representative – AAP Section on Emergency Medical Technicians
Medicine Associate Professor of Pediatrics and Emergency
Assistant Professor of Pediatrics Medicine
Johns Hopkins University School of Medicine Ohio University Heritage College of Medicine
Associate State Medical Director for Pediatrics Pediatric Medical Advisor, Medflight of Ohio
Maryland Institute of EMS Systems Medical Director, The Franklin County Firefighters
Baltimore, Maryland Grant Medical Center EMS Education Program
Columbus, Ohio
S. Heath Ackley, MD, MPH, FAAP
Representative – AAP Section on Emergency J. Joelle Donofrio-Odmann, DO, FAAP, FACEP, FAEMS
Medicine Representative – National Association of EMS
Clinical Associate Professor Physicians
Pediatric Emergency Medicine EMS Medical Director, Rady Children’s Hospital
Seattle Children’s Hospital of San Diego
Seattle, Washington Associate Medical Director, San Diego Fire-Rescue
Assistant Professor, Departments of Pediatrics and
Thomas Breyer, FF/NRP, MSHS
Emergency Medicine
Representative – International Association
UCSD School of Medicine
of Fire Fighters
San Diego, California
Director of Fire & EMS Operations
Washington, DC Joyce Foresman-Capuzzi, MSN, APRN, CCNS, CEN, CPEN,
CTRN, TCRN, CPN, EMT-P, FAEN
Kathleen M. Brown, MD, FACEP, FAAP
Representative – Emergency Nurses Association
Representative – American College of Emergency
Clinical Nurse Educator
Physicians
Lankeanu Medical Center
Professor of Pediatrics and Emergency Medicine
Prospect Park, Pennsylvania
The George Washington University School of
Medicine Susan Fuchs, MD, FAAP, FACEP
Associate Division Chief, Medical Director Co-Editor, PEPP, Fourth Edition
of Quality Representative – American Heart Association
Division of Emergency Medicine Professor of Pediatrics, Northwestern University
Children’s National Medical Center Feinberg School of Medicine
Washington, DC Attending Physician, Division of Emergency Medicine
Ann & Robert H. Lurie Children’s Hospital of Chicago
Chicago, Illinois
x
PEPP Steering Committee xi
Brandon Kelley, NRP Toni M. Petrillo, MD, FAAP

Representative – National Association of State Representative – AAP Section on Critical
EMS Officials Care/Transport Medicine
EMS Supervisor Pediatric Critical Care Fellowship Director
Wyoming Department of Health, Emergency Medical Director of Transport
Medical Services Professor of Pediatrics
Cheyenne, Wyoming Division of Pediatric Critical Care
Emory University and Children’s Healthcare
Corolla Lauck, NRP
of Atlanta
Representative – National Association of State
Atlanta, Georgia
EMS Officials
Program Director Michael J. Stoner, MD, FAAP
South Dakota Emergency Medical Services for Representative – AAP Section on Emergency
Children Program Medicine/Transport Medicine
Sioux Falls, South Dakota Assistant Professor of Pediatrics
The Ohio State University College of Medicine
Rich Martin
Section Chief of Emergency Medicine
Nationwide Children’s Hospital
of Fire Chiefs
Columbus, Ohio
Deputy Chief of Operations
Castle Rock Fire and Rescue Department Michael H. Stroud, MD, FAAP
Castle Rock, Colorado Representative – AAP Section on Critical
Care/Transport Medicine
Associate Professor
Co-Editor, PEPP, Fourth Edition
Pediatric Critical Care
EMS Coordinator, Saratoga County, New York
University of Arkansas for Medical Sciences
Executive Editor, Journal of Emergency Medical
Associate Medical Director
Services (JEMS)
Angel One Transport
EMS Editor, Fire Engineering Magazine
Little Rock, Arkansas
Nurse Clinician, Adult & Pediatric Cardiac Surgical
ICUs, Albany Medical Center Keith Widmeier, BA, NRP, FP-C
Chief Medical Officer, West Crescent Fire Representative – National Association
Department of EMS Educators
Chair, EMS Section Board – International Simulation Educator
Association of Fire Chiefs Children’s Hospital of Philadelphia
Waterford, New York Center for Simulation, Advanced Education, &
Innovation
Philadelphia, Pennsylvania
Acknowledgments
Editors Victoria Barnes, RN, BSN, EMT
Program Coordinator
Connecticut Emergency Medical Services
for Children
Mike McEvoy, PhD, NRP, RN, CCRN New Haven, Connecticut
Andrew Bartkus, RN, MSN, JD, CEN, CCRN, CFRN, NREMT-P, FP-C
Emergency Department Director
Authors Sandoval Regional Medical Center
The American Academy of Pediatrics and editors Rio Rancho, New Mexico
acknowledge with appreciation the contributions of Kathleen M. Brown, MD, FACEP, FAAP
the following individuals in the development of this Representative – American College of Emergency
resource. Physicians
Michael R. Aguilar, AA, EMT-P Professor of Pediatrics and Emergency Medicine
EMS Adjunct Faculty The George Washington University School of
Kirkwood Community College Medicine
Regional Center for EMS Education Associate Division Chief, Medical Director of Quality
Cedar Rapids, Iowa Division of Emergency Medicine
Children’s National Medical Center
Jennifer F. Anders, MD, FAAP Washington, DC
Chair, PEPP Steering Committee
Representative – AAP Section on Emergency Tabitha Cheng, MD
Medicine UCSD EMS Fellow
Assistant Professor of Pediatrics Emergency Department Physician
Johns Hopkins University School of Medicine San Diego, California
Associate State Medical Director for Pediatrics Sharon Chiumento, BS, BSN, EMT-P
Maryland Institute of EMS Systems EMS Representative – NYS EMSC Committee
Baltimore, Maryland Adjunct Faculty – Monroe Community College
S. Heath Ackley, MD, MPH, FAAP Rochester, New York
Representative – AAP Section on Emergency
Medicine
Clinical Associate Professor
Pediatric Emergency Medicine
Seattle Children’s Hospital
Seattle, Washington
xii
Acknowledgments xiii
Ann Dietrich, MD, FACEP, FAAP J. Hudson Garrett Jr., PhD, MSN, MPH, MBA, FNP-BC, PLNC,
Representative – National Association of Emergency IP-BC, AS-BC, NREMT, VA-BC, FACDONA, FAAPM, FNAP
Medical Technicians Adjunct Assistant Professor of Medicine
Associate Professor of Pediatrics and Emergency Division of Infectious Diseases
Medicine University of Louisville School of Medicine
Ohio University Heritage College of Medicine Medical Reserve Corp
Pediatric Medical Advisor, Medflight of Ohio Pro Care Emergency Medical Services
Medical Director, The Franklin County Firefighters Atlanta, Georgia
Grant Medical Center EMS Education Program
Thomas Herron, Jr. AAS, NRP
Columbus, Ohio
EMS Faculty/Clinical Coordinator
J. Joelle Donofrio-Odmann, DO, FAAP, FACEP, FAEMS Roane State Community College
Representative – National Association of EMS Knoxville, Tennessee
Physicians
Will Krost, MD, MBA, NRP
EMS Medical Director, Rady Children’s Hospital
Emergency Medicine & Flight Physician
of San Diego
Bon Secours Mercy Health, St. Vincent
Associate Medical Director, San Diego Fire-Rescue
Department of Emergency Medicine
Assistant Professor, Departments of Pediatrics and
Toledo, Ohio
Emergency Medicine
UCSD School of Medicine David LaCovey, BS, EMT-P
San Diego, California EMS Specialist
Benedum Pediatric Trauma Program
Wm. Travis Engel, DO, MSc
UPMC Children’s Hospital of Pittsburgh
Paramedic, FP-C, CCP-C
Pittsburgh, Pennsylvania
Advocate Children’s Hospital
Park Ridge, Illinois Corolla Lauck, NRP
Representative – National Association of State
John A. Erbayri, MS, NRP, CHSE
EMS Officials
Emergency Care Program Manager
Program Director
Children’s Hospital of Philadelphia
South Dakota Emergency Medical Services for
Paramedic/Field Training Officer
Children Program
Marple Township Ambulance Corps
Sioux Falls, South Dakota
Ridley Park, Pennsylvania
Rich Martin
Joyce Foresman-Capuzzi, MSN, APRN, CCNS, CEN, CPEN,
CTRN, TCRN, CPN, EMT-P, FAEN
of Fire Chiefs
Representative – Emergency Nurses Association
Deputy Chief of Operations
Clinical Nurse Educator
Castle Rock Fire and Rescue Department
Lankeanu Medical Center
Castle Rock, Colorado
Prospect Park, Pennsylvania
EMS Coordinator, Saratoga County, New York
Representative – American Heart Association
Executive Editor, Journal of Emergency Medical
Professor of Pediatrics, Northwestern University
Services (JEMS)
Feinberg School of Medicine
EMS Editor, Fire Engineering Magazine
Attending Physician, Division of Emergency
Nurse Clinician, Adult & Pediatric Cardiac Surgical
Medicine
ICUs, Albany Medical Center
Ann & Robert H. Lurie Children’s Hospital
Chief Medical Officer, West Crescent Fire
of Chicago
Department
Chicago, Illinois
Chair, EMS Section Board – International
Association of Fire Chiefs
Waterford, New York
xiv Acknowledgments
Mary Otting, RN, BSN, CEN Michael J. Stoner, MD, FAAP

EMS Coordinator Representative – AAP Section on Emergency
Ann & Robert H. Lurie Children’s Hospital Medicine/Transport Medicine
of Chicago Assistant Professor of Pediatrics
Chicago, Illinois The Ohio State University College of Medicine
Section Chief of Emergency Medicine
Sylvia Owusu-Ansah, MD, MPH, FAAP
Nationwide Children’s Hospital
Assistant Professor of Pediatrics
Columbus, Ohio
EMS/Prehospital Medical Director
UPMC Children’s Hospital of Pittsburgh Matthew R. Streger, Esq, MPA, NRP
Pediatric Liaison – Division of EMS Partner
Department of Emergency Medicine, University Keavney & Streger, LLC
of Pittsburgh Princeton, New Jersey
National Registry of EMTs Physician Board Member
Michael H. Stroud, MD, FAAP
Pittsburgh, Pennsylvania
Representative – AAP Section on Critical
Ali Paplaskas, Pharm. D., BCCCP Care/Transport Medicine
Emergency Medicine Pharmacy Specialist Associate Professor
Mercy Health St. Vincent Medical Center Pediatric Critical Care
Toledo, Ohio University of Arkansas for Medical Sciences
Associate Medical Director
Toni M. Petrillo, MD, FAAP
Angel One Transport
Representative – AAP Section on Critical
Little Rock, Arkansas
Care/Transport Medicine
Pediatric Critical Care Fellowship Director Sam Vance, MHA, LP
Medical Director of Transport Lead Project Manager
Professor of Pediatrics Prehospital Domain Lead
Division of Pediatric Critical Care State Partnership Co-Domain Lead
Emory University and Children’s Healthcare of National EMS for Children Innovation
Atlanta and Improvement Center
Atlanta, Georgia Houston, Texas
Claudia L. Phillips, MSN-Ed, RN, CEN, CPEN Keith Widmeier, BA, NRP, FP-C
Emergency Department Registered Nurse Representative – National Association of EMS
Sandoval Regional Medical Center Educators
Rio Rancho, New Mexico Simulation Educator
Michael S. Riley, NRP, EMSI
Center for Simulation, Advanced Education, &
Senior Emergency Care Educator
Innovation
Emergency Care Programs
Saranya Srinivasan, MD, FAAP Board Reviewer
Medical Director
Los Angeles County Paramedic Training Institute The editors would like to acknowledge the work of the
Santa Fe Springs, California American Academy of Pediatrics Board-appointed
reviewer.
Jennifer L. Stafford, BSN, CEN, CFRN
Unit Based Educator: Emergency Department Wendy S. Davis, MD, FAAP
UNM Sandoval Regional Medical Center American Academy of Pediatrics
Rio Rancho, New Mexico District I Chairperson
Larner College of Medicine at the University
of Vermont
Burlington, Vermont
Acknowledgments xv
EMS Reviewers Jeffery D. Gilliard, FPM/CCEMTP/NRP

EMETSEEI Institute, Inc.
Rockledge, Florida
David Anderson
North Gilliam County Health District Keith B. Hermiz, NREMT-A, I/C
Arlington, Oregon Grafton Rescue Squad, Inc.
Grafton, Vermont
Ryan K. Batenhorst, MEd, NRP, EMSI
Southeast Community College Michele M. Hoffman, MSEd, RN, NREMT
Lincoln, Nebraska James City County Fire Department
Williamsburg, Virginia
James Blivin
Training 911 Michael Hudson, NR-P, NJ MICP
Chambersburg, Pennsylvania Sea Bright Ocean Rescue
Edison, New Jersey
Rob Bozicevich, NRP
MetroAtlanta EMS Academy Sandra Hultz, NRP
Marietta, Georgia Holmes Community College
Ridgeland, Mississippi
Jason Brooks
University of South Alabama Department Joseph Hurlburt, BS, NRP
of EMS Education North Flight EMS Wexford County
Mobile, Alabama Manton, Michigan
Joshua Chan, BA, FP-C, CCP-C Timothy M. Kimble, BA, AAS, CEM, NRP
Glacial Ridge Health System Craig Co Emergency Services
Glenwood, Minnesota New Castle, Virginia
Ted Chialtas, BA, EMT-P Mark King
San Diego Fire-Rescue Department EMS MEEMS Paramedic
Training Facility Kennebec Valley Community
San Diego, California Winthrop, Maine
Kent Courtney, NRP Christopher Maeder, BA, EMT-P
EMS/Fire/Rescue Educator Chief
Essential Safety Training and Consulting Fairview Fire District
Rimrock, Arizona Poughkeepsie, New York
Lyndal M. Curry, MS, NRP Gregory S. Neiman, MS, NRP, NCEE
Southern Union State Community College Center for Trauma and Critical Care Education
Auburn, Alabama Virginia Commonwealth University
Richmond, Virginia
Kevin Curry, AS, NRP, CCEMT-P
Augusta Fire Rescue Sean Newton
Augusta, Maine Mesa Community College
Mesa, Arizona
William Faust, MPA, NRP
Western Carolina University Laurie Oelslager, EdD, NRP, CP
Cullowhee, North Carolina South Central College
North Mankato, Minnesota
Lori Gallian, BS, EMT-P
Summit Sciences Keito Oritz, Paramedic, NAEMSE II
Citrus Heights, California Jamaica Hospital Medical Center
Jamaica, New York
Fidel O. Garcia, EMT-P
Professional EMS Education Scott A. Smith, MSN, APRN-CNP, ACNP-BC, NRP, I/C
Grand Junction, Colorado Atlantic Partners EMS, Inc.
Lisbon, Maine
Rodney Geilenfeldt II, BS, EMT-P
EMSTA College
Santee, California
xvi Acknowledgments
Mark A. Spangenberg, CCP, ECG-BC, I/C Raymond C. Whatley, Jr., MBA, NRP, TP-C
Milwaukee Area Technical College George Washington University
Milwaukee, Wisconsin Washington, DC
Michael E. Tanner, FP-C, NRP, MCCP Keri Wydner Krause
WV Public Service Training, Waverly Vol. Fire Co., Lakeshore Technical College
Air Evac Lifeteam Cleveland, Wisconsin
Waverly, West Virginia
Andy Yeoh, NRP, EFOP, BS
Jennifer TeWinkel Shea, BA, AEMT Pima Community College
Regions Hospital Emergency Medical Services Vail, Arizona
Oakdale, Minnesota
Antoinette Tharrett, MSN, RN-BC, CCEMT-P, NRP
Lake Cumberland Regional Hospital
Video Shoot Acknowledgments
Russell Springs, Kentucky We would like to thank the following institutions for
their collaboration on the video and photo shoot for
A. Elizabeth Trujillo, NRP, B.S.
this project. Their assistance is greatly appreciated.
Fielding Fire Department
Fielding, Utah Lifespan Medical Simulation Center
Providence, Rhode Island
Scott Vanderkooi, MEd, NRP
Blue Ridge Community College East Kingston Fire Department
Weyers Cave, Virginia East Kingston, Rhode Island
Tom Watson, AS, AAS, Paramedic East Providence Fire Department
Chesapeake, Virginia Providence, Rhode Island
Rekeisha A. Watson-Love, AAS, NRP Warwick Fire Department
Henderson, Nevada Warwick, Rhode Island
Foreword
Information on active threat/hostile threat and
PEPP, Fourth Edition . . .Written ■■
human trafficking
by EMS for EMS ■■ Updated images
In celebration of the 20th Anniversary of the PEPP

program, we are thrilled to bring you the PEPP, Fourth Enhanced Course Features
Edition, providing prehospital professionals with ed- ■■ An Enhanced Hybrid course format, featuring
ucation that has become known as the gold standard all new small-group, case-based discussions
in pediatric emergency care. As has always been our ■■ Nine new procedural skills video clips
primary focus, content within this manual has been including Narcan, epinephrine, and albuterol
authored by a team of EMS professionals and physi- administration; tourniquet application; intranasal
cians with expertise in prehospital care. medication administration; intraosseous needle
The Provider Manual serves as the core of the insertion; supraglottic airways; spinal motion
PEPP course and has been completely updated and restriction; and length-based resuscitation tape
revised to include many exciting new additions and ■■ New case-based scenario lectures
enhancements. ■■ Interactive course activities
■■ Optional materials you can use to customize and
supplement your courses
All NEW Content
We hope you find all the enhancements and improve-
■■ New chapter on behavioral emergencies
ments to the Fourth Edition to be dynamic, innovative,
■■ New procedures on tourniquet application and
and flexible to better meet your continuing education
intranasal medication administration
needs.
■■ Enhanced section on supraglottic airways, to
include i-gel Susan Fuchs, MD, FAAP, FACEP
■■ Enhanced section on intraosseous infusion, to Mike McEvoy, PhD, NRP, RN, CCRN
include EZ-IO
xvii
© Eddie M. Sperling.
CHAPTER 1
Pediatric Assessment
Ann Dietrich, MD, FACEP, FAAP
Keith Widmeier, BA, NRP, FP-C
LEARNING OBJECTIVES
1. Describe Pediatric Education for Prehospital Professionals (PEPP) as a program that meets national education
priorities in the emergency care of children.
2. Discuss the special challenges for the prehospital professional in pediatric assessment.
3. Recognize the key features of prearrival preparation and the scene size-up.
4. Differentiate the three elements of the Pediatric Assessment Triangle (PAT).
5. Describe the important pediatric considerations for each step in the hands-on ABC sequence of the primary
assessment.
6. Recognize clinical situations requiring pain assessment and management.
7. Discuss guidelines for when to stay on scene and treat, and when to immediately transport an ill or injured child,
including appropriate mode of transport.
8. Outline the unique considerations in the additional assessment of a child, including history taking, secondary
assessment, monitoring devices, and ongoing reassessment.
CASE STUDY 1
A 9-year-old unhelmeted boy rode his bicycle out of his driveway into the path of an oncoming car. According to wit-
nesses, the car was moving about 25 mph (40 kph), the victim was struck and thrown approximately 15 ft (4.5 m), and
he was unconscious for 1 minute. On your arrival, he is crying and anxious but responds appropriately to questions. He
is complaining that his stomach hurts. He has no abnormal airway sounds, grunting, flaring, or retracting. His skin is pale.
The respiratory rate is 30 breaths/min, there are equal breath sounds with good air exchange, and the pulse oximetry
reading is 98% on room air. His heart rate is 140 beats/min, and his blood pressure is 80/40 mm Hg. Capillary refill time is
4 seconds.
1. How badly injured is this child, and which physiologic process requires your emergent attention?
2. Should this child’s pain be treated?
1
2 Chapter 1 Pediatric Assessment
Prevention involves professionals recognizing the

Introduction limitations of an emergency care system oriented to-
Caring for a critically ill or injured infant or child is ward treatment after an illness or injury occurs and
one of the most stressful duties of the prehospital pro- working to change potentially dangerous conditions
fessional. Key history may be unreliable or unknown before an event of this type occurs. Of all community
because the patient may be too young to have descrip- activities that can improve children’s overall health
tive language, or the child may be afraid and unable to and well-being, prevention of acute injury and illness
accurately recount the key events. The caregiver may is by far the most cost-effective. “Making a difference,”
be sobbing, frightened, and anxious for reassurance. as described in detail in Chapter 17, involves new roles
Examination may be limited because of the child’s for prehospital professionals in injury and illness pre-
small size and resistance to hands-on evaluation. Vital vention, in their professional day-to-day duties, and
signs may be deceptive because of normal age-based as part of their activities as community leaders and
variations and the difficulty in obtaining them accu- health advocates
rately. It is the job of the prehospital professional to Accurate assessment of a child with an illness or
bring comfort to the child, caregiver, or family and injury requires special knowledge and skills. For pa-
to bring order to the chaos on scene. The prehospital tients of all ages, the prehospital professional’s evalu-
professional must conduct an accurate assessment and ation includes four steps: (1) scene size-up; (2) use of
deliver effective emergency treatment to the child. the Pediatric Assessment Triangle (PAT); (3) pri-
The Pediatric Education for Prehospital Profes- mary assessment using the ABCDE assessment,
sionals (PEPP) course, developed by the American vital signs, and pulse oximetry; and (4) secondary
Academy of Pediatrics (AAP), provides the core assessment, including a focused history, focused
cognitive knowledge and skills to prepare prehospi- examination, monitoring devices, ongoing reassess-
tal professionals for comprehensive assessment and ment of physiologic status, and response to treatment.
management of any ill or injured infant and child. The primary and secondary assessments have well-de-
PEPP materials are designed to meet the national fined components that follow the same sequence used
emergency medical services (EMS) education stan- for adult patients. However, all four steps in the pri-
dards for all levels of emergency medical provider, as mary assessment have important pediatric modifica-
established by the United States Department of Trans- tions. The tertiary assessment includes laboratory and
portation’s National Highway Traffic Safety Adminis- radiologic tests that can include point-of-care labs in
tration (NHTSA). Therefore, some of the terminology the prehospital setting, but are usually performed in
previously used in PEPP (general, initial, and addi- the ED.
tional assessment) has been modified to reflect the
national EMS core content and the Definitions and
Assessment Approaches for Emergency Medical Ser- Summary of Assessment
vices for Children document.
Effective emergency care of children involves
Flowchart
many professionals inside and outside of the hospi- This chapter introduces a flowchart that reflects the
tal setting. Two of the most important concepts for sequence of pediatric assessment taught by the PEPP
comprehensive and high-quality prehospital pedi- course. The flowchart reinforces the interconnecting
atric emergency care are teamwork and prevention. relationships of the different assessment components.
Teamwork involves professionals working together Sometimes the assessment sequence must be stopped
to develop and implement comprehensive clinical after the primary assessment to allow the prehospital
services, professional education, and appropriate professional to treat potentially life-threatening prob-
administrative oversight specifically for children. A lems and initiate transport. For example, when a child
Pediatric Emergency Care Coordinator (PECC) can has a critical injury, the secondary assessment must be
act as a liaison between EMS agencies and the hos- deferred until after the child has been resuscitated and
pital setting. Agency PECCs can help with protocol stabilized. Reassessment, however, is required in every
development, pediatric case reviews, agency pediat- case to monitor response to treatment, guide further
ric quality assurance/quality improvement (QA/QI), interventions, and assist with transport and triage de-
ensure the presence of adequate pediatric supplies, cisions. Monitoring devices such as a pulse oximeter
assist in injury prevention activities, help promote or end-tidal CO2 monitor and bedside glucose checks
family-centered care, identify local pediatric trends, may provide valuable adjunctive data to confirm and
and coordinate with emergency departments (EDs). guide treatment in the prehospital setting.
The Pediatric Assessment Triangle 3
Scene Size-Up
Pediatric Assessment Triangle (PAT)
Primary Assessment
Hands-on ABCDEs
Vital Signs
Pulse Oximetry
Transport Decision: Stay or Go
Secondary Assessment
History Taking
Physical Exam
Monitoring Devices FIGURE 1-1 Environmental assessment.
Courtesy of Rhonda J. Hunt.
Ongoing Reassessment
Evaluating the setting includes an inspection of

Scene Size-Up the physical environment and watching family–child
On the way to the scene, prepare mentally to approach or caregiver–child interactions (FIGURE 1-1). For ex-
and treat an infant or child, and to interact with a dis- ample, documenting observations of dangerous scene
tressed family. This means planning for a pediatric conditions and inappropriate statements from caregiv-
scene size-up, pediatric equipment and medication re- ers greatly assists child protective services if the child
quirements, and age-appropriate assessment. All pedi- is later determined to be a victim of inflicted injury
atric equipment and medications should be routinely or negligence. On the scene, be like a sponge; soak up
checked, as they are less often used by most prehospital as much useful information as possible. Also, ensure
professionals and it is easy to forget their application. scene safety for both your team and the child.
The information from dispatch on age and gender of
the child, location of the scene, and chief complaint or
mechanism of injury (or both) is the basis for prear- The Pediatric Assessment
rival preparation.
At the scene, begin the size-up by looking for pos-
Triangle
sible safety threats to the prehospital professionals, After the scene size-up, begin an assessment of the
child, caregiver, and/or bystanders. Examples of safety child, which must have a developmentally appropriate
threats include spilled toxins, open containers of al- approach. This assessment includes a visual and audi-
cohol, drug paraphernalia, weapons, or fire. The child tory general impression of the child and uses the PAT
actually may be a safety threat if he or she has an infec- as a standardized method to gather this information.
tious disease, such as varicella or meningococcemia. Rapid assessment is essential to determine the
level of acuity and urgency for treatment and trans-
port. Ask yourself, “Is the patient sick or not sick?”
TIP In the case of a child who is a victim of trauma with
a known mechanism of injury, or of a child with a
On the way to the scene, mentally rehearse your clear-cut complaint of pain in a specific anatomic lo-
approach to the assessment and treatment of an cation, the assessment may be straightforward. Still,
infant or child and the expected interaction with a careful evaluation is needed to identify less obvious,
caregiver or family. Dispatch information, when avail- but potentially serious, injuries or physiologic insta-
able, about the child’s age can be helpful to mentally bility. For a child with an illness, the assessment may
prepare for age-appropriate developmental consid- be much trickier. The prehospital professional must
erations and for anticipating equipment and medi- elicit information on the onset, duration, severity, and
cation requirements for assessment and treatment. progression of symptoms, often from a child who can-
not accurately provide such history. Moreover, illness
complaints may be vague and less specific to an ana- Developing a General Impression: The PAT
tomic region. Whether the child has an injury or an
The PAT is an easy tool to use during the rapid assess-
illness, the PAT helps to identify physiologic instabil-
ment of any child (FIGURE 1-2). It allows the prehospital
ity, direct resuscitation priorities, and determine the
professional to develop a first general impression of the
timing of transport.
patient’s status with only visual and auditory clues. By us-
ing the PAT at the point of first contact with the patient,
Scene Size-Up the prehospital professional can immediately establish a
level of severity, determine urgency for life support, and
identify the general type of physiologic problem. Contin-
ued use of the PAT gives the prehospital professional a
way to track response to therapy and determine timing of
Primary Assessment transport. It also allows for communication among med-
Hands-on ABCDEs ical professionals about the child’s physiologic status and
Vital Signs for accurate radio reporting.
Pulse Oximetry There are three components of the PAT that together
Transport Decision: Stay or Go reflect the child’s overall physiologic status: (1) appearance,
(2) work of breathing, and (3) circulation to the skin. The
Secondary Assessment PAT is based on listening and seeing and does not require
a stethoscope, blood pressure cuff, cardiac monitor, or
History Taking
pulse oximeter. The PAT should be completed in less than
Physical Exam
30 seconds and is designed to organize a time-honored
Monitoring Devices process of “across the room assessment,” an intuitive pro-
Ongoing Reassessment cess that experienced pediatric providers do instinctively.
TIP
TIP
The elements of the PAT incorporate auditory and visual
Use the PAT at the point of initial contact with every clues that should be obtained from“across the room,”with-
child, regardless of age or presenting complaint. out appearing threatening to an already anxious child.
Work of
Appearance Breathing
Circulation to Skin
FIGURE 1-2 Pediatric Assessment Triangle (PAT).

The PAT interactiveness, consolability, look/gaze, and speech/

cry (TABLE 1-1).
Together, the physical characteristics of the PAT pro
Identifying abnormal appearance is a better way to
vide an accurate initial picture of the child’s underlying
detect subtle abnormalities in behavior than the con-
cardiopulmonary status and level of consciousness.
ventional “alert, verbal, painful, unresponsive”
Although the PAT does not necessarily lead to a di-
(AVPU) scale or the Pediatric Glasgow Coma Scale
agnosis, it identifies the general category of the physi-
(GCS) for neurologic evaluation. Most children with
ologic problem and establishes urgency for treatment
mild to moderate illness or injury are “alert” on the
or transport. The PAT does not replace traditional vital
signs and the ABCs, which are part of the primary as-
sessment in the next phase of the physical evaluation. CAUTION
The patient characteristics emphasized by the three In assessing patients with mild to moderate illness or
arms of the PAT did not originate with PEPP. Experi-
injury, numerical “scoring” methodologies and severity
enced pediatric health care providers developed these
scales for levels of consciousness are rarely useful. These
characteristics to share the intuitive assessment skills to
classical neurologic evaluation systems work best in pa-
obtain a rapid first general impression of ill or injured
children. What is unique about the PAT is its systematic tients with severe injury or illness as a tool to monitor
approach to making, integrating, and communicating for changes in children with serious brain dysfunction.
these observations. The PAT is the cornerstone of the
PEPP course. Use the PAT in every encounter with every AVPU or “15” on the Pediatric GCS. Children with
child. Over time, it will become an indispensable and an abnormal appearance must be assumed to have a
spontaneous method for making a rapid initial “sick or potentially serious underlying problem. Therefore,
not sick” assessment of ill or injured children of all ages. assessing a child’s appearance is the most useful first
thing to do in evaluating every pediatric patient.
Appearance
Characteristics of Appearance. The child’s general TIP
appearance is the most important factor in determin-
Never ignore the pale infant, the “nobody home
ing the severity of the illness or injury, the need for
stare,” or the infant who does not respond appropri-
treatment, and the response to therapy. Appearance
ately to stimulation.
reflects the adequacy of ventilation, oxygenation,
brain perfusion, body homeostasis, and central
nervous system (CNS) function. There are many Techniques to Assess Appearance. Assess the child’s
characteristics of appearance; the most important are appearance from the doorway. This is Step 1 in the PAT.
summarized in the “tickles” (TICLS) mnemonic: tone, Techniques for assessment of a conscious child’s appearance
TABLE 1-1 Characteristics of Appearance: The “Tickles” (TICLS) Mnemonic
Characteristic Features
■■ Tone Is she moving or vigorously resisting examination? Does she have good muscle tone? Or is she
limp, listless, or flaccid?
■■ Interactiveness How alert is she? How readily does a person, object, or sound distract her or draw her
attention? Will she reach for, grasp, and play with a toy or examination instrument, such as a
penlight? Or is she uninterested in playing or interacting with the caregiver?
■■ Consolability Can she be consoled or comforted by the caregiver? Or is her crying or agitation unrelieved by
gentle reassurance?
■■ Look/Gaze Does she fix her gaze on a face? Or is there a “nobody home,” glassy-eyed stare?
■■ Speech/Cry Is her speech or cry strong and spontaneous? Or is it weak, muffled, or hoarse?
Adapted from Dieckmann RA, Brownstein D, Gausche-Hill M. The Pediatric Assessment Triangle: a novel approach to pediatric assessment. Pediatr Emerg Care. 2010:26;312–315.
include observing from a distance; allowing the child to re-

TIP
main in the caregiver’s lap or arms; using distraction tools,
such as bright lights or toys, to measure the child’s ability The child’s general appearance is the single most im-
to interact; and kneeling down to be at eye level with the portant feature when assessing severity of illness or
child. An immediate “hands-on” approach may cause agi- injury, need for treatment, and response to therapy.
tation and crying and may complicate the assessment. Un-
less a child is unconscious or obviously critically ill, get as
much information as possible by observing the child An abnormal appearance may have many causes: in-
before touching the child or taking vital signs. adequate oxygenation, ventilation, or brain perfusion;
One example of a child with a normal appearance systemic abnormalities, such as poisoning, infection, or
is an infant who holds himself or herself upright in the hypoglycemia; or acute or chronic brain injury. Re-
mother’s arms, makes good eye contact, and has good gardless of the cause, a child with a grossly abnormal
color (FIGURE 1-3). An example of an infant with a wor- appearance is seriously ill or injured and needs immedi-
risome appearance is an infant who makes poor eye ate life support efforts to increase oxygenation, ventila-
contact with the caregiver or prehospital professional tion, and perfusion.
and is pale and listless (FIGURE 1-4).
CAUTION
Although an alert, interactive child is usually not crit-
ically ill, there are some exceptions to the reliability
of general appearance as an indicator of stable car-
diopulmonary and neurologic function. The most
common exceptions are ingestions with delayed
physiologic effects and blunt injury with slow inter-
nal bleeding.
Although an alert, interactive child is usually not

critically ill, there are some cases where a child may
have life-threatening problems despite an initially nor-
mal appearance. Toxicologic or traumatic emergencies
are good examples:
1. A child with acetaminophen, iron, or a cyclic
antidepressant overdose may not show symptoms
FIGURE 1-3 A child making good eye contact is normal and immediately after ingestion. Despite the child’s nor-
a sign of a good appearance. mal appearance, he or she may develop deadly com-
© Photos.com.
plications in the coming minutes or hours.
2. A child with blunt trauma and solid organ injury
may be able to maintain adequate core perfusion,
despite internal bleeding, by increasing cardiac
output and systemic vascular resistance; therefore,
he or she may appear normal during the primary
assessment. However, when these compensatory
mechanisms fail, the child may acutely “crash,”
with rapid progression to decompensated
shock. Pallor may be the only finding on the PAT
that suggests impending disaster.
A benign appearance should never justify a denial of
transport. However, a normal appearance usually means
that a transport with lights and siren is not necessary.
FIGURE 1-4 A limp, pale child unable to make eye contact Age differences are associated with important devel-
or a child with retractions may be critically ill or injured. opmental differences in psychomotor and social skills.
© CGN089/Shutterstock. “Normal” appearance and behavior vary by age group,
as discussed in Chapter 2. Children of all ages engage Snoring, muffled or hoarse speech, and stridor sug-
their environment: newborns do this through energetic gest an upper airway obstruction. Snoring or gurgling
sucking and crying; older infants, by smiling or track- occurs when the oropharynx is partially obstructed by
ing a light; toddlers through physical exploration; and the tongue and soft tissues. Muffled or hoarse speech
adolescents through speech. Knowledge of normal child reflects inflammation of the glottis or supraglottic
development through the age groups should guide the structures. Stridor is a high-pitched sound heard on
assessment of appearance and result in more accurate inspiration, or during inspiration and expiration, re-
treatment and transport decisions. Although appear- flecting an obstruction at the level of the glottis or
ance reflects the severity of illness or injury, it does not subglottic trachea. All of these sounds reflect abnor-
identify the cause. Appearance is the “screening” por- mal airflow through partially obstructed upper airway
tion of the PAT. The other elements of the PAT (work structures. Obstruction of the upper airway passages
of breathing and circulation to the skin) provide more can occur in a variety of illnesses and injuries, includ-
specific information about the type of physiologic de- ing croup, foreign body aspiration, and bacterial upper
rangement, while giving additional clues about severity. airway infections, or as a result of bleeding or edema.
Abnormal lower airway sounds that may be heard
Work of Breathing during the PAT include grunting and wheezing.
Grunting is a sound produced by partial closure of
Characteristics of Work of Breathing. In children,
the glottis on the end of expiration. Grunting is a
work of breathing is a more accurate indicator of oxy-
form of auto positive end-expiratory pressure, a way
genation and ventilation than respiratory rate or breath
to distend lower respiratory tract air sacs (alveoli) to
sounds on auscultation, the standard measures of breath-
promote maximum gas exchange. Grunting involves
ing effectiveness in adults. Work of breathing reflects the
exhaling against a partially closed glottis. This short,
child’s attempt to compensate for abnormalities in ox-
low-pitched sound is best heard at the end of the exha-
ygenation and ventilation, and it is a proxy for the ef-
lation and is easily mistaken for whimpering.
fectiveness of gas exchange. This component of the PAT
Grunting is often present in children with moder-
requires listening carefully for abnormal airway sounds
ate to severe hypoxia, and it reflects poor gas exchange
and looking for signs of increased breathing effort. It is
because of obstruction in the lower airways and alve-
another “hands-off ” evaluation method that does not re-
oli. Conditions that cause hypoxia and grunting are
quire a stethoscope or pulse oximeter. TABLE 1-2 summa-
pneumonia, pulmonary contusion (bruising of the
rizes the key characteristics of work of breathing.
lungs), and pulmonary edema (fluid in air sacs).
Abnormal Airway Sounds. Examples of abnormal Wheezing is the result of movement of air across
airway sounds that can be heard without a stethoscope partially blocked small airways. At first, wheezing usu-
are snoring, muffled or hoarse speech, stridor, grunt- ally occurs during exhalation and can be heard only
ing, and wheezing. Abnormal airway sounds provide by auscultation of the chest with a stethoscope. As the
information about the physiology and anatomic loca- airway obstruction increases and breathing requires
tion of the breathing problem. more work, wheezing is often present during inhala-
tion and exhalation. With more obstruction, wheez-
ing may be audible without a stethoscope. Finally, if
TABLE 1-2 Characteristics of Work of Breathing respiratory failure develops, work of breathing may
Characteristic Features to Look For TIP

Abnormal airway Snoring, muffled or hoarse speech, Grunting is the only airway sound noted that is not
sounds stridor, grunting, wheezing where the problem is occurring (i.e., upper airway
sound with lower lung tissue disorder).
Abnormal Sniffing position, tripoding, re-
positioning fusing to lie down
Retractions Supraclavicular, intercostal, or TIP

substernal retractions of the chest
Abnormal airway sounds can provide excellent in-
wall; head bobbing in infants
formation about breathing effort, type of breathing
Flaring Flaring of the nares on problem, location of the breathing problem, and po-
inspiration tential degree of hypoxia.
FIGURE 1-5 The sniffing position opens up the airways to

improve patency.
diminish and the wheezing may not be heard at all.

The most common cause of wheezing in childhood is
asthma, although wheezing may also be associated FIGURE 1-6 The abnormal tripod position indicates the
with bronchiolitis (a viral respiratory infection in in- patient’s attempts to maximize accessory muscle use.
fants) and lower airway foreign body aspiration.
Visual Signs of Increased Work of Breathing. retractions, expose the child’s chest. Retractions are a
There are several useful visual signs of increased work more useful measure of work of breathing in children
of breathing. These signs reflect an increased breathing than in adults, because a child’s chest wall is less mus-
effort by the child to improve oxygenation and venti- cular and the inward excursion of skin and soft tissue
lation. The presence of certain physical features, such between the ribs is more apparent. Retractions may be
as abnormal positioning, retractions, and nasal flaring, in the supraclavicular area (above the clavicle), the
reflects overall illness or injury severity. Abnormal po- intercostal area (between the ribs), or the substernal
sitioning is usually evident from the doorway. There area (under the sternum), as illustrated in FIGURE 1-7.
are several types of abnormal postures that can indicate Another form of accessory muscle use seen only in in-
the child is struggling to improve airflow. A child who fants is “head bobbing,” which is the use of neck mus-
is in the sniffing position is trying to align the axes cles to assist breathing during times of severe hypoxia.
of the airways to improve patency and increase airflow The infant extends the neck as he or she inhales and
(FIGURE 1-5). This position is usually the result of severe then allows the head to fall forward as he or she exhales.
upper airway obstruction. The child who refuses to Nasal flaring is another sign of increased work of
lie down, or who leans forward on outstretched arms breathing (FIGURE 1-8). Nasal flaring is the exagger-
(tripoding), is creating optimal mechanical position- ated opening of the nostrils during labored inspiration
ing to use accessory muscles of respiration (FIGURE 1-6). and indicates moderate to severe hypoxia. It reflects the
The sniffing position and tripoding are abnormal and child’s extra effort to breathe during hypoxic stress,
indicate airway obstruction, increased work of breath-
ing, and severe respiratory distress.
TIP
Retractions are physical signs of increased work
of breathing. Retractions represent the recruitment Head bobbing is a form of accessory muscle use spe-
of accessory muscles of respiration to provide more cific to infants and is indicative of increased work of
“muscle power” to move air into the lungs in the face of breathing.
airway or lung disease or injury. To optimally observe
sniffing position or tripoding. Next, have the caregiver

uncover the chest of the child for direct inspection, or
have the child undress on the caregiver’s lap. Look for
intercostal, supraclavicular, and substernal retractions,
and note if there is head bobbing in infants. After ex-
amining for retractions, inspect for nasal flaring. This
stepwise process is critical for gathering accurate in-
formation. After an infant or child begins to cry, as-
sessment of work of breathing becomes more difficult.
Children may have increased work of breathing
because of abnormalities anywhere in their upper or
lower airways, alveoli (air sacs), pleura (membrane
surrounding the lungs and lining the walls of the pleu-
FIGURE 1-7 Retractions indicate increased work of ral cavity), or chest wall. The type of abnormal airway
breathing and may occur in the supraclavicular, intercostal, sounds gives an important clue to the anatomic location
and substernal areas. of the illness or injury process, whereas the number and
© AePatt Journey/Shutterstock.
type of physical signs of increased work of breathing
help in determining the degree of physiologic stress.
Combining assessment of appearance and work
of breathing can also help establish the severity of the
child’s illness or injury. A child with a normal appear-
ance and increased work of breathing is in respiratory
distress. An abnormal appearance and increased work
of breathing suggest respiratory failure. An abnormal
appearance and abnormally decreased work of breath-
ing imply impending respiratory arrest.
Circulation to Skin
Characteristics of Circulation to Skin. The goal of
rapid circulatory assessment is to determine the ade-
quacy of cardiac output and core perfusion or perfu-
sion of the vital organs. The child’s appearance is one
indicator of brain perfusion, but abnormal appearance
may be caused by other conditions unrelated to circu-
lation, such as hypoxia, hypoglycemia, brain injury, or
intoxication. For this reason, other signs of adequacy
of perfusion must be added to the evaluation of ap-
pearance to assess the child’s true circulatory status.
An important sign of core perfusion is circulation
to the skin. When cardiac output is inadequate, the
body shuts down circulation to nonessential anatomic
FIGURE 1-8 Nasal flaring indicates increased work of areas, such as the skin and mucous membranes, to
breathing and moderate to severe hypoxia. preserve blood supply to the most vital organs (brain,
© Hemera/Thinkstock. heart, and kidneys). Therefore, circulation to the skin
reflects the overall status of core circulation. Pallor,
usually caused by such conditions as croup, pneumo- mottling, and cyanosis are key visual indicators of
nia, asthma, bronchiolitis, or pulmonary contusion. reduced circulation to the skin and mucous mem-
branes. TABLE 1-3 summarizes these characteristics.
Techniques to Assess Work of Breathing. Step 2 Pallor may be the first sign of poor skin or mu-
in the PAT is assessing work of breathing. Begin by cous membrane perfusion; it may be the only visual
listening carefully from a distance for abnormal air- sign apparent in a child with compensated shock and
way sounds. Next, look for key physical signs. Note if indicates reflex peripheral vasoconstriction to shunt
the child has an abnormal posture, most notably the blood away from the skin to the core. Pallor may also
levels) generates a respiratory alkalosis and helps to

TABLE 1-3 Characteristics of Circulation to Skin restore normal pH (blood acid–base balance). Effort-
less tachypnea is different from the rapid and labored
Characteristic Features to Look For respirations that are present with illnesses and injuries
associated with airway or lung pathology.
Pallor White or pale mucous membrane col-
oration from inadequate blood flow Techniques to Assess Circulation to Skin. Step 3
in the PAT is evaluating circulation to the skin. Be
Mottling Patchy skin discoloration caused by sure the child is exposed long enough for visual in-
vasoconstriction or vasodilation spection but not long enough to become cold. A cold
child may have normal core perfusion but abnormal
Cyanosis Bluish discoloration of skin and mu- circulation to the skin. Cold circulating air tempera-
cous membranes
ture is the most common reason for misinterpretation
of skin signs, and an exposed young infant may be-
come hypothermic quickly, even at normal ambient
be a sign of anemia or hypoxia. Mottling is another temperatures.
sign of inadequate skin perfusion, reflecting vasomo- Inspect the skin and mucous membranes for pallor,
tor instability (abnormal blood vessel tone) in the cap- mottling, and cyanosis. Look at the face, chest, abdo-
illary beds of the skin. Mottled skin has patchy areas men, and extremities, and then inspect the lips for cya-
of vasoconstriction (pallor) mixed with areas of nosis. In dark-skinned children, circulation to the skin is
vasodilation (cyanosis or erythema). Mottling may sometimes more difficult to assess, and the lips, mucous
also be a normal physiologic response in a child ex- membranes, and nail beds are the best places to look for
posed to cold environmental temperatures. pallor or cyanosis (FIGURE 1-9). Combining assessment
Cyanosis is blue discoloration of the skin and of appearance and circulation to the skin can also help
mucous membranes. It is the most extreme visual establish the severity of the child’s illness or injury. A
indicator of poor perfusion or poor oxygenation. Do child with a normal appearance and poor circulation to
not confuse acrocyanosis (blue hands and feet in a the skin is possibly cold. An abnormal appearance and
newborn or infant less than 2 months of age) with true circulation to the skin suggests the child is in shock.
cyanosis. Acrocyanosis is a normal finding when a
young infant is cold, and it reflects vasomotor insta- Using the PAT to Evaluate Severity and Illness
bility rather than hypoxia or shock. True cyanosis is a or Injury. The PAT provides a general impression of
late finding of respiratory failure or shock. A hypoxic the pediatric patient. The intent is to provide a stan-
child is likely to show other physical abnormalities dardized approach to the “general impression” and an
long before turning blue. These abnormalities may in- immediate picture of the child’s physiologic status. By
clude abnormal appearance with agitation or lethargy combining the three components of the PAT, the pre-
and increased work of breathing. A child in shock may hospital professional should be able to answer three
also have pallor or mottling. Never wait for cyanosis critical questions: (1) How severe is the child’s illness
to begin treatment with supplemental oxygen. How- or injury? (2) What is the most likely physiologic ab-
ever, the presence of cyanosis is always a critical sign normality? (3) What is the urgency for treatment? This
that requires immediate intervention with breathing information helps the prehospital professional select
support. the most important actions: how fast to intervene,
Abnormal circulation to the skin, in combination what type of general and specific treatments to give,
with an abnormal appearance, suggests shock. How- and how rapidly to transport.
ever, the abnormalities in appearance in early phases The three elements of the PAT work together and
of compensated shock may be subtle, and some chil- allow a rapid assessment of the child’s overall physi-
dren may remain alert. As perfusion worsens and ologic stability. For example, if a child is interactive
compensatory mechanisms fail, appearance becomes and pink, but has mild intercostal retractions, the
abnormal, reflecting inadequate delivery of oxygen prehospital professional can take time to approach
and glucose to the brain. Another clue to the presence the child in a developmentally appropriate manner
of shock is effortless tachypnea, or tachypnea to complete the primary assessment. However, if the
without signs of increased work of breathing. Effort- child is limp, with unlabored rapid breathing and pale
less tachypnea is a reflex mechanism that allows the or mottled skin, shock is likely. In this case, the pre-
body to blow off carbon dioxide to compensate for the hospital professional must move rapidly through the
metabolic acidosis caused by poor peripheral perfu- primary assessment and begin resuscitation. A child
sion (lactic acidosis). Hypocarbia (low blood CO2 who has an abnormal appearance, but normal work of
Primary Assessment 11
FIGURE 1-9 In dark-skinned children, circulation to the skin is sometimes more difficult to assess, and the lips, mucous
membranes, and nail beds may be the best places to look for pallor or cyanosis.
breathing and normal circulation to skin, probably has

a primary brain dysfunction or a major metabolic or Scene Size-Up
systemic problem, such as postictal state, subdural
hemorrhage, concussion, intoxication, hypoglyce- Pediatric Assessment Triangle (PAT)
mia, or sepsis.
The PAT has two important advantages. First, it al- Primary Assessment
lows the examiner to quickly obtain critical information Hands-on ABCDEs
about the child’s physiologic status before touching or Vital Signs
agitating the child. Second, the PAT helps set priorities Pulse Oximetry
for the rest of the hands-on primary assessment. The Transport Decision: Stay or Go
PAT takes only seconds, it helps to identify the need for
lifesaving interventions, and it assists in the transition
into the next phase of hands-on physical assessment.
History Taking
The three components of the PAT (appearance,
Physical Exam
work of breathing, and circulation to the skin) can be
assessed in any sequence, unlike the ordered ABCDEs Monitoring Devices
of resuscitation discussed next. Ongoing Reassessment
TIP
By combining the three components of the PAT, the It provides a prioritized sequence of life-support in-
prehospital professional can answer three critical terventions to reverse critical physiologic abnormali-
questions: (1) How sick or injured is the child? (2) What ties. As in adults, there is a specific order for treating
is the most likely physiologic abnormality? (3) What is life-threatening problems as they are identified, before
the urgency for treatment? moving to the next step. The steps are the same, but
there are important pediatric differences in anatomy,
physiology, and signs of distress. ABCDE assessment
Primary Assessment involves the following components:
1. Airway
Hands-on ABCDEs 2. Breathing
The primary assessment continues the process of 3. Circulation
identifying life-threatening conditions using an or- 4. Disability
dered hands-on physical evaluation of the ABCDEs. 5. Exposure
Airway
TABLE 1-4 Normal Respiratory Rate for Age
The PAT may identify the presence of an airway obstruc-
tion based on the presence of abnormal airway sounds. Age Respiratory Rate (breaths/min)
However, the loudness of the stridor or wheezing is not
necessarily related to the amount of airway obstruction. Infant 30–60
For example, children with asthma in severe distress
may have little or no wheezing. Similarly, children with Toddler 24–40
an upper airway foreign body below the vocal cords
may have minimal stridor. Abnormal positioning and Preschooler 22–34
retractions provide further information about the de-
gree of obstruction, as does the quality of air entry on School-aged child 18–30
auscultation during the hands-on assessment.
If the airway is open, ensure that the chest rises Adolescent 12–16
with each breath. If a child has assumed a position
that maximizes his or her ability to maintain a sponta-
neously open airway, allow the child to remain in that
position of comfort. If gurgling is present, there may Scene Size-Up
be mucus, blood, or a foreign body in the mouth or
upper airway. Oropharyngeal suctioning of mucus or Pediatric Assessment Triangle (PAT)
blood, or removal of a visible foreign body, very often
restores patency. If the airway is totally obstructed, ad- Primary Assessment
vanced life support (ALS) interventions are necessary. Hands-on ABCDEs
Vital Signs
Breathing Pulse Oximetry
Respiratory Rate. Verify the respiratory rate per min- Transport Decision: Stay or Go
ute by counting the number of chest rises in 30 seconds,
then doubling that number. Interpret the respiratory Secondary Assessment
rate carefully. Normal infants may show “periodic History Taking
breathing” or variable respiratory rate with short (<10 Physical Exam
second) periods of apnea. Therefore, counting for only Monitoring Devices
10–15 seconds may give a falsely low respiratory rate.
The significance of respiratory rates may be confus-
ing. Rapid respiratory rates may simply reflect high fe-
ver, anxiety, pain, or excitement. Normal rates, however,
may occur in a child who has been breathing rapidly age), especially with abnormal appearance or marked
with increased work of breathing for some time and is retractions, indicates respiratory distress and possibly
now becoming fatigued. Finally, interpretation requires respiratory failure. An abnormally slow respiratory
knowledge of normal values for age (TABLE 1-4). rate is always worrisome because it might mean respi-
ratory failure. Red flags are respiratory rates less than
20 breaths/min for children younger than 6 years of
TIP age and less than 12 breaths/min for children between
6 and 18 years of age. A normal respiratory rate alone
“Red flag” respiratory rates are less than 20 breaths/
never guarantees adequate oxygenation and ventila-
min for children younger than 6 years of age and
tion. The respiratory rate must be interpreted along
less than 12 breaths/min for children between 6 and with appearance, work of breathing, and air movement.
18 years of age.
Pulse Oximetry
Serial assessment of respiratory rates may be es- Oxygen Saturation. Pulse oximetry is an excellent
pecially useful, and the trend is sometimes more ac- tool to assess how well a child is oxygenating. FIGURE 1-10
curate than any single value. A sustained increase or illustrates the technique of placing a pulse oximetry
decrease in respiratory rate is usually significant. probe on a young child. In infants and younger children,
Pay close attention to extremes of respiratory rate. the patient may tolerate the probe more readily if a wrap
A very rapid respiratory rate (>60 breaths/min for any around probe is used and it is placed around the toe or
Midclavicular line
Anterior axillary line
Midaxillary line
FIGURE 1-11 Listen for air movement over the midaxillary line.
pulse oximetry alone. Again, interpret pulse oximetry

together with the rest of the assessment to accurately
evaluate the degree of respiratory distress or failure.
B Auscultation. Listen with a stethoscope over the mid-
FIGURE 1-10 A. Various pulse oximeter probes wrap clavicular and midaxillary lines during inhalation
around or clip onto digits or earlobes. B. Pulse oximetry and exhalation to hear abnormal lung sounds, such
is an excellent tool for assessing the effectiveness of as crackles and wheezing (FIGURE 1-11). Inspiratory
oxygenation. crackles indicate disease in the alveoli (air sacs) them-
B: tnkorn yangaun/Shutterstock.
selves. Often, crackles are not heard on auscultation,
even when the child has a pathologic condition, such as
the foot. Covering the extremity with a blanket, sock, or pneumonia. The younger the child, the more difficult it
towel may also help improve tolerance of the probe. A is to appreciate abnormal sounds during auscultation.
pulse oximetry reading above 94% saturation on room Expiratory wheezing indicates lower airway obstruc-
air indicates good oxygenation. Be careful not to under- tion. Auscultation also helps evaluate the volume of
estimate respiratory distress in a child with a reading air movement and effectiveness of work of breathing.
above 94%. Sometimes the child can compensate for A child with increased work of breathing and poor air
hypoxia by significantly increasing work of breathing movement may be in impending respiratory failure.
and respiratory rate, and pulse oximetry may not reflect TABLE 1-5 lists abnormal breath sounds, their
the true severity or urgency of the respiratory problem. causes, and common examples of associated disease
As with any other measurement, interpret pulse oxime- processes.
try in the context of the “big picture,” including work of
breathing, appearance, and circulation. Circulation
Although pulse oximetry is quite helpful in iden- The PAT provides important visual clues about circula-
tifying a child with moderate respiratory distress, it tion to the skin. Information obtained from the hands-on
can also help identify the child in respiratory failure. evaluation of heart rate, pulse quality, skin temperature,
When the pulse oximetry reading is below 90% satu- capillary refill time, and blood pressure provides further
ration in a child on 100% oxygen by a nonrebreathing information on the adequacy of perfusion.
mask, this usually represents respiratory failure re-
quiring assisted ventilation. However, sometimes Heart Rate. Methods used to assess adult circulatory
a child in severe respiratory distress or early respira- status (heart rate and blood pressure) have important
tory failure may maintain measured oxygen satura- limitations in children. First, normal heart rate varies
tion by increasing work of breathing and respiratory with age, as noted in TABLE 1-6. Second, tachycardia
rate. This child may not appear to be critically ill by may be an early sign of hypoxia or poor perfusion,
TABLE 1-5 Interpretation of Abnormal Breath Sounds
Sound Cause Examples
Stridor Upper airway obstruction Croup, foreign body aspiration,

retropharyngeal abscess
Wheezing Lower airway obstruction Asthma, foreign body, bronchiolitis
Expiratory grunting Inadequate oxygenation Pulmonary contusion, pneumonia, drowning
Inspiratory crackles Fluid, mucus, or blood in airway Pneumonia, pulmonary contusion
Absent breath sounds despite Severe airway obstruction (upper Physical barrier to transmission of breath
increased work of breathing or lower airway) sounds, foreign body, severe asthma,
hemothorax, pneumothorax, pleural fluid,
pneumonia
TABLE 1-6 Normal Heart Rate for Age TIP

A rapid initial respiratory rate may simply reflect high
Age Heart Rate (beats/min)
fever, anxiety, pain, excitement, and not any real
Infant 100–160 physiologic or anatomic problem. Noting a trend of
an abnormal respiratory rate is more useful for indi-
Toddler 95–150 cating true pathology.
Preschooler 80–140
leading to frank bradycardia. Bradycardia indicates
School-age child 70–120 critical hypoxia or ischemia. With tachycardia greater
than 180 beats/min, an electronic monitor is necessary
Adolescent 60–100 to accurately determine heart rate.
Pulse Quality. Feel the pulse to ascertain pulse qual-

but it may also reflect fever, anxiety, pain, and excite- ity. Normally, the brachial pulse is palpable in the
ment. Like respiratory rate, interpret heart rate within medial aspect of the antecubital fossa (FIGURE 1-
the context of the overall history, PAT, and primary 12). Note the quality as either weak or strong. If the
assessment. A trend of increasing or decreasing heart brachial pulse is strong, the child is probably not
rate may be quite useful: It may suggest worsening hy- hypotensive. If a peripheral pulse cannot be felt, at-
poxia or shock or improvement after treatment. When tempt to find a central pulse. Check the femoral pulse
hypoxia or shock becomes critical, the heart rate falls, in infants and young children or the carotid pulse
CASE STUDY 2
A 3-year-old boy was found face down in the family swimming pool. He was under water for no more than 1 minute but
required cardiopulmonary resuscitation by the mother to get him breathing again. On arrival of EMS, the child is alert,
pink, and clinging to his mother. Respirations appear regular and nonlabored. When you examine him further, he screams
and fights you. His respiratory rate is 26 breaths/minute, but you are unable to obtain a blood pressure or heart rate or
assess lung sounds. The mother is sobbing and frightened.
1. How useful is the PAT in evaluating severity of illness and urgency for care?
2. How is the PAT different from the ABCDEs in the primary assessment?
CAUTION
Be careful not to underestimate respiratory distress in
a child with a pulse oximetry reading above 94%. This
child may be using increased work of breathing and
tachypnea to compensate for serious hypoxic stress.
TIP
Interpret heart rate in the context of the overall his-
tory, PAT, and entire physical assessment.
CONTROVERSY
The value of capillary refill time is controversial. Periph-
eral perfusion may be variable in some children, and
such environmental factors as ambient temperature
FIGURE 1-12 The anatomic position of the brachial pulse is
may have a strong influence on capillary refill time.
in the medial aspect of the antecubital fossa.
when performed consecutively on a child who is not

in an older child or adolescent. If there is no pulse, cold.
or the pulse is low (<60 beats/min) and the child is
symptomatic with poor circulation, start cardiopul- Blood Pressure. Blood pressure determination
monary resuscitation (CPR) (see Chapter 5 for more and interpretation may be difficult in children be-
information). cause of the lack of patient cooperation, confusion
about proper cuff size, and problems remember-
Skin Temperature and Capillary Refill Time. ing normal values for age. FIGURE 1-13A illustrates
Next, do a hands-on evaluation of circulation to the the different sizes of blood pressure cuffs, and FIG-
skin. Although children with normal circulation may URE 1-13B demonstrates the technique for getting a
have cool hands and feet, the skin should be warm correct blood pressure in the arm or thigh. Always
above the wrists and ankles. With decreasing per- use a cuff with a width of two-thirds the length of
fusion, the extremities become cooler proximally. the upper arm or thigh. For patients 3 years of age
Check capillary refill time in a fingertip, toe, or heel or younger, technical difficulties reduce the value
or on the pads of the fingertips. Normal capillary re- of a blood pressure in the field. When shock is sus-
fill time is less than 2 to 3 seconds. The value of mea- pected in this age group based on other assessments
suring capillary refill time is controversial for several (e.g., history, mechanism, PAT), consider attempting
reasons: the peripheral perfusion baseline may vary blood pressure once on scene, but do not delay treat-
from child to child; environmental factors, such as ment or transport. In a child who is clearly unstable
cold room temperature, may complicate interpreta- (requiring assisted ventilation, absent radial or fem-
tion; and it may be difficult for the prehospital pro- oral pulses), begin immediate resuscitation and delay
fessional to accurately count seconds under critical blood pressure until child is in a more stable condi-
circumstances. The capillary refill time is just one tion. For stable patients older than 3 years of age, try
element in the assessment of circulation. It must be one blood pressure measurement in the field, then
evaluated in the context of the PAT and other perfu- move on to the rest of the assessment.
sion characteristics, such as heart rate, pulse quality, For children older than 1 year of age, an easy for-
and blood pressure. mula for determining the lower limit of acceptable
Signs of circulation to the skin (skin temperature, blood pressure by age is as follows: minimal systolic
capillary refill time, and pulse quality) are helpful blood pressure should be greater than 70 + (2 × age
tools to assess a child’s circulatory status, especially in years). For example, a 2-year-old toddler with a
do not delay transport to obtain a blood pressure. Re-

member, a normal blood pressure measurement may
be misleading. Although a low blood pressure defi-
nitely indicates hypotensive shock, a “normal” blood
pressure frequently exists in children with compen-
sated shock.
Note that a widening pulse pressure (systolic pres-
A sure minus diastolic pressure) may occur secondary to
increased intracranial pressure and early septic shock;
a narrowing pulse pressure may be seen early in hypo-
volemic shock.
TIP
For patients younger than 3 years of age, the value
of obtaining a blood pressure in the field may be
outweighed by the technical difficulties of getting
an accurate measurement. Focus on immediate re-
suscitation in a child with an unstable airway, tachy-
cardia and poor perfusion or absent radial or femoral
pulses, and delay blood pressure until child’s condi-
B
tion stabilizes.
FIGURE 1-13 A. There are several different blood pressure
(BP) cuff sizes: neonatal, infant, child, and adult. B. To obtain
an accurate BP reading, use a cuff that is two-thirds the
length of the child’s upper arm. CAUTION
B. © Jones & Bartlett Learning. Courtesy of Glen Ellman.
Do not depend on blood pressure readings to diag-
nose shock. A “normal” blood pressure frequently ex-
systolic blood pressure of 65 mm Hg is hypotensive. ists in compensated shock.
TABLE 1-7 shows approximate normal minimal systolic
blood pressure values for different ages. High blood
pressure is usually not a clinical problem for children Disability
in the field. Assume that a blood pressure is within
Assessment of disability, or neurologic status, involves
normal limits if an infant or young child is agitated,
quick evaluation of the two main parts of the CNS:
is crying, has pink skin, and has easily palpable pe-
the cerebral cortex and the brainstem. First assess
ripheral pulses. In a patient with this clinical profile,
neurologic status, which is controlled by the cerebral
cortex, by looking at appearance as part of the PAT;
then assess the level of consciousness using the AVPU
TABLE 1-7 Minimum Systolic Blood Pressure by Age scale (TABLE 1-8). Evaluate the brainstem by checking
the responses of each pupil to a direct beam of light.
Minimal Systolic Blood A normal pupil constricts after a light stimulus. Pu-
Age Pressure (mm Hg) pillary response may be abnormal in the presence
of drugs, ongoing seizures, hypoxia, or impending
Infant (birth to 12 mo) >60 brainstem herniation. Next, evaluate motor activity.
Look for symmetric movement of the extremities, sei-
Toddler (1–3 yr) >70 zures, posturing, or flaccidity.
Preschooler >75
CAUTION
School-age child >80
Neither the AVPU scale nor the Pediatric GCS allows
Adolescent >90 assessment of restless or agitated behavioral states.
TABLE 1-8 AVPU Scale
Category Stimulus Response Type Reaction
Alert Normal environment Appropriate Normal interactiveness for age
Verbal Simple command or Appropriate or Responds to name; nonspecific or

sound stimulus inappropriate confused
Painful Pain Appropriate, Withdraws from pain or sound or motion

inappropriate, or without purpose or localization of pain;
pathologic posturing
Unresponsive No perceptible response to any stimulus
AVPU Scale. The AVPU scale is a standardized value to highest are (1) no response, (2) extensor
method of assessing the level of consciousness in all posturing, (3) flexor posturing, (4) withdrawing,
patients. It helps categorize motor response based on (5) localizing, and (6) obeying instructions (as
simple responses to stimuli. The patient is either alert, age-appropriate). Like the AVPU scale, the GCS does
responsive to verbal stimuli, responsive only to painful not address degrees of neurologic disability in chil-
stimuli, or unresponsive. dren who are restless, agitated, or combative.
Abnormal Appearance and the AVPU Scale. As- Exposure

sessment of appearance using the PAT provides dif-
Proper exposure of the child is necessary for completion
ferent information than assessment using the AVPU
of the primary physical assessment. The PAT requires
scale. A child with an altered mental status (AMS) on
that the caregiver remove part of the child’s clothing
the AVPU scale always has an abnormal appearance
to allow careful observation of the face, chest wall, and
in the PAT, because such a child almost always has a
skin. Completing the ABCDE components of the pri-
serious or critical condition. However, a child with a
mary assessment may require further exposure to fully
mild to moderate illness or injury may be alert on the
evaluate physiologic function, anatomic abnormalities,
AVPU scale, but have an abnormal appearance in the
and unsuspected injuries. Pay attention to the need for
PAT. Assessing appearance using the PAT may provide
privacy, even for prepubescent children, when possible.
an earlier indication of the presence of serious illness
and injury.
The accuracy of the AVPU scale is controversial,
and it has a few important limitations. Its ability to Scene Size-Up
predict the extent of neurologic compromise has not
been well tested in children. Its scope is limited in Pediatric Assessment Triangle (PAT)
the evaluation of children with restless or agitated
states. The scale only addresses decreased levels of re-
Primary Assessment
sponsiveness, a problem common to all of the current
prehospital methods for disability assessment. How- Hands-on ABCDEs
ever, it is easy to remember (there are no numbers Vital Signs
to recall) and to use. The more complicated Pediat- Pulse Oximetry
ric GCS involves memorization and numerical scor- Transport Decision: Stay or Go
ing, tasks that may be hard to remember and apply
in critical situations (TABLE 1-9). Recent data suggest Secondary Assessment
that the motor component of the GCS alone is the History Taking
best predictor of neurologic outcome. The much sim- Physical Exam
pler-to-administer motor component of the GCS may Monitoring Devices
be adequate for mental status evaluation in the field. Ongoing Reassessment
The motor categories of the GCS from lowest point
TABLE 1-9 Pediatric Glasgow Coma Scale
Score Child Infant
Eyes
4 Opens eyes spontaneously Opens eyes spontaneously
3 Opens eyes to speech Opens eyes to speech
2 Opens eyes to pain Opens eyes to pain
1 No response No response
_______ = Score (Eyes)
Motor
6 Obeys commands Spontaneous movements
5 Localizes Withdraws to touch
4 Withdraws Withdraws to pain
3 Flexion Flexion (decorticate)
2 Extension Extension (decerebrate)
_______ = Score (Motor)
Verbal
5 Oriented Coos and babbles
4 Confused Irritable cry
3 Inappropriate words Cries to pain
2 Incomprehensible words Moans to pain
_______ = Score (Verbal)
_______ = Total Score (Eyes, Motor, Verbal). Scores will range from 3 to 15.
James HE, Anas NG, Perkin RM. Brain Insults in Infants and Children. Orlando, FL: Grune & Stratton; 1985. Reprinted with permission.
Be careful to avoid heat loss, especially in infants, by heat when left exposed. Cold stress in critically ill or in-
covering the child up as soon as possible. Infants and jured patients can increase metabolic demands, worsen
younger children have a larger body surface to body the effects of hypoxia and hypoglycemia, and adversely
weight ratio and are at a greater risk to rapidly lose body affect the response to resuscitative efforts.
Summary of Primary Assessment 19
provider. Similarly, the risk of brain injury is decreased

Primary Assessment: The if glucose is administered to the unconscious diabetic
Transport Decision: Stay or Go? child at the time that the prehospital professional rec-
ognizes hypoglycemia with a bedside test.
After completing the PAT and the hands-on ABCDEs
and beginning resuscitation as necessary, the prehos-
pital professional must make a crucial decision: should
EMS System Regulations
he or she immediately transport the child to the ED, or The decision to stay or go often is defined by EMS sys-
should he or she continue with the additional assess- tem regulations about treatment and transport. For
ment and treatment on scene? Should he or she trans- example, some systems allow prehospital profession-
port the child, or is there a more appropriate mode of als to treat a child in cardiopulmonary arrest with ALS
transport available (e.g., aeromedical services, pedi- interventions until either the resuscitation is success-
atric specialty transport teams)? Should the child be ful or death is declared. Other systems require trans-
transported to a local community hospital, for either port after initial resuscitation is under way, with the
treatment or stabilization, or does the child need to decision to discontinue efforts left to the ED staff.
go directly to a trauma center or pediatric specialty
hospital? This decision process is different for each Comfort Level
child and for each EMS system. While vital signs and Whenever a prehospital professional believes that the
pulse oximetry are listed in the primary assessment, illness or injury requires a higher level of care, it is best
the transport decision can be made if the prehospital to initiate transport quickly. Moreover, whenever the
provider determines the need for expedited transport prehospital professional feels uncomfortable with a
after using the PAT and evaluating the ABCDEs. critical intervention, it is best to transport and attempt
the intervention on the way to the ED, rather than on
TIP scene. For example, a child with hypotensive (decom-
pensated) shock usually deserves one attempt at vas-
Deciding when to go and when to stay is different for cular access on scene, then fluid administration on the
each child and for each EMS system. way to the ED. The time spent on multiple intravenous
attempts on scene might be better spent in transport-
ing the child to definitive care, where the underlying
TIP cause of shock can be more appropriately addressed.
If the child is physiologically unstable, defer or omit Transport Time

history taking and physical examination on scene
The time to the nearest ED is another key factor. A
and perform en route.
shorter transport time ordinarily supports a shorter
scene time. For example, if a child has ingested a po-
tentially lethal poison, immediate transport is prudent
Expected Benefits of Treatment if the ED is close by, because of the complications re-
The time it takes to reach definitive care in the hospi- lated to delay of definitive care. However, if transport
tal has a major effect on the outcomes of children with time is long, consider initiating treatment on scene.
serious injuries. The time it takes to reach hospital care Prehospital providers should also consider the pediat-
may also significantly affect the outcomes of children ric capabilities of the area EDs compared to the criti-
with certain medical illnesses. For example, a child in cality of the pediatric patient. While pediatric patients
cardiogenic shock benefits most from rapid transport to are best served at pediatric hospital EDs, the criticality
definitive care, because the hospital is the best place for of the patient may cause the prehospital provider to
lifesaving treatments of this rare and complex condition. transport a critical pediatric patient to the closest ED
However, some critically ill children benefit from so he or she can be stabilized before being transported
basic life support (BLS) and ALS treatment on scene. to a pediatric hospital.
For example, for a child who is seizing, early treatment
with a benzodiazepine is the best hope to get the seiz-
ure under immediate control and avoid additional
anticonvulsant administration and advanced airway
Summary of Primary Assessment
management. A child with an anaphylactic reaction The components of the pediatric primary assessment
requires an intramuscular (IM) epinephrine injection include the PAT, the ABCDEs, immediate resusci-
from an autoinjector or drawn up by a BLS or ALS tation needs, and transport decision. The PAT is the
basis for the general impression. It includes evaluation If the child seems to be physiologically unsta-
of the characteristics of appearance, work of breathing, ble based on the primary assessment, the prehospi-
and circulation to the skin and uses clues obtained by tal professional may decide to transport immediately
looking and listening from across the room. The pri- and defer the history and secondary assessment. If
mary assessment includes a hands-on evaluation of the child is stable and the scene is safe, the prehos-
pediatric-specific indicators of cardiopulmonary or pital professional should obtain a thorough history
neurologic abnormalities. Although vital signs can and complete the secondary assessment on the scene
be useful in the primary assessment, they can also be and before transport. As opposed to the primary as-
misleading. They must be interpreted in the context sessment, which focuses on physiologic problems that
of age and the overall general and primary assess- may be immediately life-threatening, this secondary
ments. Interventions may be necessary at any point assessment focuses on anatomic abnormalities, which
in the ABCDE sequence. After the ABCDEs, another are rarely life-threatening.
crucial decision is whether to stay on scene and begin A history should be obtained from the caregiver of
treatment or transport immediately. The type of clini- the pediatric patient or from the caregiver and the older
cal problem, the expected benefits of earlier transport, child or adolescent. In some cases, it may be helpful to
the local EMS policies, the prehospital professional’s interview the adolescent separate from the caregiver;
comfort level, and the transport time are all important many adolescents are hesitant to disclose information
elements in the transport decision. about drug use or sexual activity (as it relates to the
current illness or injury) in front of their caregiver. The
history provides important information that assists
TIP the prehospital professional in analyzing assessment
Always perform reassessment to track problems and findings. The SAMPLE mnemonic may be used to elicit
monitor response to treatment.
information: Signs and Symptoms, Allergies, Medica-
tions, Past medical problems, Last food or liquid, and
Events leading up to this illness or injury (TABLE 1-10).
Scene Size-Up
TABLE 1-10 Pediatric SAMPLE Components
Component Explanation
Primary Assessment
Signs and Onset and nature of symptoms of
Hands-on ABCDEs
symptoms pain or fever
Vital Signs Age-appropriate signs of distress
Pulse Oximetry
Transport Decision: Stay or Go Allergies Known drug reactions or other
allergies
Medications Exact names and doses of
History Taking
ongoing drugs
Physical Exam Timing and amount of last dose
Monitoring Devices Timing and dose of analgesics or
Ongoing Reassessment antipyretics
Past medical History of pregnancy, labor, delivery

Secondary Assessment: History problems Previous illness or injuries
Immunizations
Taking Last food or Timing of the child’s last food
History taking has two objectives and should be per- liquid or drink, including bottle or
formed on both medical and trauma patients: breastfeeding
1. To obtain a complete description of the main
Events leading Key events leading to the current
complaint to the injury or incident
2. To determine the mechanism of injury or circum- illness Fever history
stances of illness
Physical Examination 21
Children with special health care needs often re- Use the toe-to-head sequence for the detailed sec-
quire additional history collection, but the type of hist- ondary assessment of infants, toddlers, and preschool-
ory necessary is dependent on the underlying illness ers. This approach allows the prehospital professional
or condition. The use of an Emergency Information to gain the child’s trust and cooperation and increases
Form (EIF) can be extremely helpful in obtaining crit- the accuracy of the physical findings. Ask for the as-
ical information about these patients. More informa- sistance of the caregiver in the assessment. Note the
tion about children with special health care needs can following special anatomic characteristics of children
be found in Chapter 10. when performing the secondary assessment.
If a child has an apparently minor condition (e.g.,
low-grade fever, feeding difficulties, fussiness, minor
trauma), be careful not to overlook clues to possible General Observations
serious underlying conditions. Ingestions, metabolic Observe the clothing for any unusual odors or for
problems, and systemic infections may present with stains that might suggest a poison. If poisoning is sus-
nonspecific findings in infants and toddlers. Consider pected, remove soiled or dirty clothing and save it, and
child maltreatment when the physical findings are not wash the child’s skin with soap and water.
logically related to the complaint leading to the call or
if the history is implausible or changes.
Skin
Observe the skin carefully for rashes and bruising pat-
Scene Size-Up terns that may suggest maltreatment, as discussed in
Chapter 11. Look for bite marks; straight line marks
from cords or straps; pinch marks; or hand, belt, or
buckle pattern bruises. Patterned injuries, or those
with a geometric shape, are often indicative of abuse.
Primary Assessment
Inspect for nonblanching petechial or purpuric le-
Hands-on ABCDEs sions (which may indicate severe infections), and look
Vital Signs for any new lesions that develop during transport.
Pulse Oximetry
Head
Secondary Assessment The younger the infant or child, the larger the head is
History Taking in proportion to the rest of the body (FIGURE 1-14). This
Physical Exam disproportionate size increases the risk for head injury
Monitoring Devices with deceleration, such as in motor vehicle crashes.
Ongoing Reassessment Look for bruising, swelling, and hematomas. Signif-
icant blood can be lost between the skull and scalp of
a small infant. Assessment of the anterior fontanelle
in infants younger than 9–18 months old can pro-
Physical Examination vide helpful information (FIGURE 1-15). If possible,
the fontanelle should be assessed with the infant in a
Often, this portion of the assessment is not possible sitting position, and when not crying. A bulging and
because of transport and treatment priorities. Some- nonpulsatile fontanelle suggests elevated intracra-
times it is unnecessary because the problem has been nial pressure caused by meningitis, encephalitis, or
fully evaluated in earlier phases of the assessment or intracranial bleeding. A sunken fontanelle suggests
the complaint and history are minor or well localized dehydration.
(e.g., minor laceration or twisted ankle).
If the child with traumatic injuries is stable on
scene and does not need resuscitation after the pri- Eyes
mary assessment, or if he or she is on the way to the A thorough evaluation of pupil size, reaction to light,
hospital but does not require ongoing treatment, per- and symmetry of extraocular muscle movements
form a detailed secondary assessment. This physical may be difficult to perform in infants. Gently rocking
evaluation must include all anatomic areas affected infants in the upright position often gets them to open
and builds on the findings of the primary assessment their eyes. A colorful distracting object can then be
and history taking. used to help assess eye movements.
2 Months 5 Months Newborn 2 years 6 years 12 years 25 years

(fetal) (fetal)
FIGURE 1-14 The relationship of the head to the body changes with advancing age.
Modified from McKinney ES et al: Maternal child nursing, ed 3, St. Louis, 2009, Saunders.
Anterior
Normal skull of the newborn
Metopic
suture
Anterior
fontanel
Coronal
suture
Sagittal
suture
Posterior
Lambdoid
fontanel
suture
Posterior
FIGURE 1-15 The anterior fontanelle of the infant is a window to the CNS.
Nose
Young infants preferentially breathe through their
noses, so nasal congestion with mucus can cause
marked respiratory distress. Gentle bulb or catheter
suction of the nostrils may bring relief (FIGURE 1-16).
In a trauma patient, leaking blood (rhinorrhea) or
cerebrospinal fluid (CSF) suggests a basilar skull
fracture.
Ears
Look for any drainage from the ear canals (otorrhea).
Bruises to the ear pinna, especially in a nonambulatory
child, may suggest inflicted trauma. Leaking blood or FIGURE 1-16 Gentle bulb suction may bring relief to the infant.
CSF suggests a basilar skull fracture. Check for bruises The National Association of State EMS Officials
behind the ear or Battle sign, another indicator of currently recommend spinal motion restriction for
basilar skull fracture. The presence of pus may indi- children with neck pain, an inability to move the
cate an ear infection or perforation of the eardrum neck, focal neurologic deficit, altered mental status,
(tympanic membrane). high-risk mechanism (i.e., high-speed motor vehi-
cle collision, diving), torso trauma, or a predisposing
Mouth condition.
In the trauma patient, look for active bleeding and
loose teeth. In nonambulatory children, mouth trauma Chest
may be a sign of inflicted trauma. Note the smell of Reexamine the chest for penetrating injuries, lac-
the breath. Some ingestions are associated with iden- erations, bruises, or rashes. If the child is injured,
tifiable odors, such as hydrocarbons. Acidosis, as feel the clavicles and every rib for tenderness or
in diabetic ketoacidosis, may impart a sweet or deformity.
“fruity” smell to the breath.
Back
Neck
Inspect the back for lacerations, penetrating injuries,
Examine the trachea for edema or bruising. Listen bruises, or rashes.
with a stethoscope over the trachea at the midline
(FIGURE 1-17). This is a quick and easy way to differen-
tiate between very proximal airway obstruction (usu- Abdomen
ally mucus in the nose) and true wheezing or stridor. Inspect the abdomen for any bruising, swelling, de-
The neck should also be assessed for a tracheal shift or formities, or rashes. Multiple bruises or bruises in
jugular vein distention (JVD). These are classic signs different stages of healing on the chest or abdomen
of tension pneumothorax, but occur late in the phys- may be associated with inflicted injury. In the trauma
iologic process. JVD may not be present if there are patient, redness or bruising under the site of protec-
other injuries present that have led to hypovolemia. tive straps, or “seat belt sign,” may be apparent. A
Assess for neck tenderness. “handlebar” mark may also be present if a child had
contact with the handlebar of a bicycle during an ac-
cident. Both seat belt marks and handlebar injuries
are associated with significant internal injuries. Also,
inspect the abdomen for distention. Gently palpate
the abdomen, and watch closely for guarding or tens-
ing of the abdominal muscles, which may suggest
infection, obstruction, or intra-abdominal injury.
Note any tenderness or masses. If an infant or toddler
has been crying for a prolonged period of time, or if
a child’s respiratory effort has been supported with
a bag-mask device, this may also lead to abdominal
distention because of air that has been pushed into
the stomach.
Extremities
Assess for symmetry. Compare both sides for color,
warmth, size of joints, and tenderness. Put each joint
through a full range of motion while watching the
eyes of the child for signs of pain; understandably, if
there is obvious deformity of the extremity suggesting
a fracture, this technique should not be used, and the
extremity should be splinted. If there is a suspected
FIGURE 1-17 Listen at the trachea to distinguish the origin fracture present, assess for a pulse, capillary refill,
of abnormal airway sounds. motor function, and sensation distal to the injury.
Fractures in nonambulatory children are suspicious procedures without the benefit of analgesia. Posttrau-
for inflicted trauma. matic stress is also more common among children
who experience pain during acute illness and injury
Additional Vital Signs and do not receive pharmacologic relief. Hence, just as
with adults, it is essential to carefully assess pain in all
Although pulse and respirations have been assessed
children and to consider effective methods to provide
in the primary assessment, they may or may not have
relief from suffering when appropriate.
been formally counted and recorded because of cir-
Local EMS protocols now require that prehospital
cumstances of resuscitation or brevity of transporta-
professionals assess and manage pain as a part of the
tion. It is important to obtain and record these vital
secondary assessment. Indeed, evaluation of pain has
signs to assess and monitor the child’s changing condi-
become a new vital sign in all ages, including children.
tion. When resuscitation is necessary, pulse and respi-
Appropriate pain management relieves distress of the
rations should be monitored frequently, but additional
child and family or caregivers and facilitates commu-
vital signs may be deferred until the child has stabi-
nication, physical assessment, and ease of transport.
lized or the transportation is completed.
Assessment of pain must take into consideration
the developmental age of the patient. The ability to rec-
Assessment of Pain ognize pain improves as the age of the child increases.
It is easy for the prehospital professional to ignore, For example, in a preverbal infant, crying and agita-
underestimate, or misinterpret the signs and symp- tion unrelieved by being held by the caregiver may be
toms of pain in infants and young children. Chil- caused by hunger, hypoxia, or pain. In infants, further
dren are much less likely to receive effective pain assessment is essential to identify sources of pain be-
medications than adults. Studies have demonstrated fore administration of analgesia. In contrast, verbal
reluctance by all levels of emergency care personnel children older than 3 years of age are usually quite vo-
to administer medications to children for control cal about pain. Therefore, in older children, pain scales
of pain and anxiety. The younger the child, the less using pictures of facial expressions (Wong-Baker
likely the child will receive effective analgesia and FACES Scale) or visual analogue scores (VAS) may
anxiolysis. However, adult and pediatric experience be helpful in assessing the need for pharmacologic
has validated the effectiveness of analgesia in the relief of pain. FIGURE 1-18 illustrates the Wong-Baker
prehospital setting to decrease pain, without causing FACES Scale. Although such “self-report” scales have
respiratory depression or interference with the accu- not yet been extensively used in the prehospital en-
racy of physical assessment. vironment, they have been validated in other settings
Pain is present with most types of injuries and to provide an immediate evaluation of intensity of
with many illnesses. Inadequate treatment of pain has pain and to monitor response to treatment.
many adverse effects on the child and family. Pain it- There is much overlap between the management
self causes significant morbidity and misery for the of fear and anxiety and the management of pain in
child and family or caregivers and interferes with the infants and young children. Many nonpharmacologic
prehospital professional’s accurate assessment of phys- and pharmacologic methods relieve anxiety and re-
iologic abnormalities. Children who do not receive duce the perception of pain, as summarized in TABLE 1-
appropriate analgesia are more likely to have exagger- 11. Remaining calm and providing quiet, professional
ated pain responses to subsequent painful procedures. reassurance to caregivers and child are the first im-
Even neonates have demonstrable chronic changes in portant steps. A calm caregiver helps to make the child
pain perception when they are subjected to painful calm and more at ease. Distraction techniques may be
0 2 4 6 8 10
NO HURT HURTS HURTS HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST
FIGURE 1-18 Wong-Baker FACES Pain Rating Scale for self-assessment of pain.
Wong-Baker FACES Foundation (2019). Wong-Baker FACES® Pain Rating Scale. Retrieved with permission from http://www.WongBakerFACES.org.
TABLE 1-11 Methods of Prehospital Analgesia and

Anxiolysis
Nonpharmacologic
Calm manner
Caregiver assistance through presence or holding
Distraction techniques with “toolbox” of toys
Ice
Visual imagery
Pacifier FIGURE 1-19 Use distraction techniques to help reduce the

child’s pain.
Music
Splinting of fractures TIP

Pain is often considered an additional vital sign. Pain
Pharmacologic
management can help relieve distress of the child
Morphine and family, greatly facilitate communication and
physical assessment, assist in timely provision of nec-
Fentanyl essary interventions, and ease the transport process.
Midazolam
Ketamine CONTROVERSY
Nitrous oxide Although “self-report” pain scales have not yet been
extensively used for pediatric patients in the prehos-
Benzodiazepines pital environment, they have been validated in other
clinical settings. They can help provide an immediate
12%–25% sucrose for neonates evaluation of pain intensity, and they can aid in mon-
itoring response to treatment.
Acetaminophen
Ibuprofen (no ibuprofen for infants <6 months)

Pharmacologic methods for reducing pain are
also a standard of prehospital care. Opiates, benzo-
extremely helpful in reducing pain. Many prehospital diazepines, ketamine, and nitrous oxide are available
providers learn to use toys, “magic tricks,” or engaging to prehospital professionals in many EMS systems.
stories to provide distraction. Some EMS systems have Intramuscular medications are less effective be-
developed a “toolbox” with distraction equipment to cause children fear needles, and the injection site pain
facilitate pain relief (FIGURE 1-19). Keeping the care- may last for days. Analgesic and anxiolytic drugs may
giver with the child and sometimes holding the child be easily delivered through inhalation techniques, by
are also useful strategies. the transmucosal (e.g., sublingual, intranasal, and
In older children, visual imagery techniques can rectal) route, or by the transdermal route, although
often be helpful. Ask the child where he or she would experience is still limited. Several techniques, such
most prefer to be at the present time, then assist the as inhaled nitrous oxide, intranasal fentanyl, inhaled
child in closing his or her eyes and visualizing a more midazolam, and rectal diazepam, have had excel-
tranquil or enjoyable environment. Music is also a lent success in prehospital pediatric care. However,
very effective distraction. the fastest method for administration of analgesia
and anxiolysis is by way of the intravenous route. In-

travenous delivery provides the most effective and
Additional Monitoring Devices
most controllable or titratable method. A downside The prehospital professional can perform some types
is it does involve establishing vascular access, which, of specific testing in the field, such as rapid glucose
like the IM route, is usually painful. Also, the child’s determinations, point-of-care lactate, 12-lead elec-
response to pain and anxiolytic medication is some- trocardiogram monitoring, waveform capnography,
times unpredictable and must be carefully weighed and other specialty testing available based on local
against unwanted side effects. Medications to reduce protocols.
pain also cause sedation and can result in respiratory
depression, bradycardia, hypoxemia, hypotension,
and even loss of protective airway reflexes. Occasion- Scene Size-Up
ally, anxiolytic drugs cause a paradoxical worsening of
agitation. Pediatric Assessment Triangle (PAT)
Primary Assessment
TIP Hands-on ABCDEs
Analgesic and anxiolytic drugs may be easily deliv- Vital Signs
ered through inhalation, transmucosal (e.g., intrana- Pulse Oximetry
sal, sublingual, rectal), or transdermal routes. Several Transport Decision: Stay or Go
techniques, such as inhaled nitrous oxide, intranasal
fentanyl, intranasal midazolam, inhaled naloxone, Secondary Assessment
and rectal diazepam, have had excellent success in History Taking
prehospital pediatric care. Physical Exam
Monitoring Devices
Assessment of pain has become a “vital sign,” and
management of pediatric pain and anxiety must be
a routine part of field care in all EMS systems. This Ongoing Reassessment
entails a thorough understanding of available non-
pharmacologic techniques, medications, potential Perform reassessment of all patients to gauge the re-
medication contraindications and complications, and sponse to treatment and to track the progression of
management of those complications. identified physiologic and anatomic problems. New
problems may also be identified on reassessment. Data
from the reassessment will guide ongoing treatment.
The elements in the reassessment are as follows:
Scene Size-Up
1. The PAT
2. The ABCDEs with repeat vital signs
3. Assessment of positive anatomic findings
4. Review of the effectiveness and safety of treatment
Primary Assessment
Hands-on ABCDEs The elements in the reassessment are also the
Vital Signs
basis for determination of an appropriate transport
destination and for accurate, pediatric-specific radio
Pulse Oximetry
or telephone communications with medical oversight
or the ED.
History Taking Radio Reporting
Physical Exam Proper radio reporting promotes a seamless transfer
Monitoring Devices of care from the prehospital to the ED setting, maxi-
Ongoing Reassessment mizing the ability of all clinicians to provide efficient
and effective care. A good radio report transmits
Another random document with
no related content on Scribd:
"Ka nousee, jos noustakseen, tai ei nouse." Sellainen se on
pyyntimiehen lykky.
*****
Itä-Karjala on mineraaleista rikkaimpia osia koko maassamme.

Geoloogit eli kivennäistieteen tutkijat sanovat, että siellä löytyy
vähän kaikkia. Tärkeimmät siellä löytyvät vuorilajit, malmit ja
mineraalit nähdään tästä luettelosta.
[Tämä luettelo on tehty vuori-insinööri G. Lisitzin'in antamien

tietojen mukaan.]
Wuorilajeja:
Dioriittia ja diabaassia. Kiillegneissiä.

Dolomiittia. Kvartsia.
Feltspaattia. Kvartsiittia.
Gneissi-graniittia. Marmoria.
Graniittia. Rapakiveä.
Hornblende-gneissiä. Saviliuska-kiveä.
Kalkkikiveä. Sordavaliittia.
Malmeja ja mineraaleja:
Apatiittia. Lyijyhohdetta.
Arsenikki-kiisua. Magneetista rautamalmia.
Berylliä. Malakiittia.
Euxeniittia.. Pitkärandiittia.
Grafiittia. Pyrhotiinia.
Granaatteja (eri värisiä). Rikkikiisua.
Järvi-rautamalmia. Sinkkivälkettä.
Kuparihohdetta. Tinamalmia (kassiteriittia).
Kuparikiisua. Turmaliinia.
Lazurikiveä. Werikivi-malmia.
Noin 30 kilometriä pohjoiseen Sortavalan kaupungista on

Ruskealan marmorilouhos. Marmorivuori on jotenkin laaja eikä se
vielä ole louhoten suuresti huvennut. Ovat kuin maantien rakentajien
kuoppia hiekkasärkässä, louhoskohdat. Kestää sieltä vielä toinen
mokoma ottaa ja jääpi sittenkin tähdettä monen suuren kaupungin
palatsirakennuksiksi.
Kuten tiedetään, ovat Iisakinkirkko ja useat Pietarin kaupungin

palatseista Ruskealan marmoria. Marmorilohkareita vietiin entiseen
aikaan suunnattoman suuria Pietariin. Ne sahattiin ensin Ahinkosken
sahassa, joka on muutamia kilometrejä marmorilouhoksesta. Täysin
muodostettuina kuljetettiin ne sitten Laatokkaan laskeumalle
Helylänjoelle, jossa ne lastattiin laivoihin ja vietiin määräpaikkaansa.
Useita päiviä viipyi suuri marmorilohkare tuolla lyhyellä tiellä

louhoksen ja lastauspaikan välillä. Siinä sitä oli Sortavalan miehillä
työtä ja rahdinansion tilaisuutta. Lohkare kohotettiin ensin reen
tapaiselle laitokselle ja hevosia valjastettiin viisin-kuusinkymmenin
peräkkäin kuorman eteen. Jokaisen hevosen selässä istui
ajajapoika, ruoska kädessä, ja kivikuorman päällä seisoi
päällysmies, heiluttaen kepillä merkiksi pojille, milloin heidän tuli
sivaltaa hevosiaan selkään, jotta näin yht'aikaa nykähyttäisivät
kuormaa eteenpäin.
Wiimeisinä vuosikymmeninä on Ruskealan marmoria käytetty

vaan kalkin polttoon. Kerrotaan kuitenkin, että Suomen valtio, joka
omistaa marmorilouhoksen, aikoisi nyt uudestaan ruveta louhomaan
sieltä marmoria, Pietarin kirkkojen ja palatsien tarpeeksi. Sitä varten
rakennettanee Karjalan rautatieltä pieni haararatakin
marmortlouhokselle.
Louhostyö tietysti tulisi tapahtumaan suomalaisten insinöörien

johdolla ja kotimaista työväkeä tultaisiin käyttämään. Wenäjän
kruunu näet entisinä aikoina käytti omia urakoitsijoitaan ja paljon oli
silloin venäläistä työväkeä Ruskealassa.
Ruskealan marmori on enimmäkseen vaaleanharmaata. Tapaa

siellä kuitenkin toisiakin värivivahduksia: vehreätä, valkoista ja
kellertävää; ei kuitenkaan suuremmassa määrin.
Sortavalan kaupungin alueella löytyy erästä vuorilajia, joka

harvinaisuutensa vuoksi tässä mainittakoon. Wäriltään on se
kiiltävän mustaa, muistuttaa pikeä. Kuuluisa maanmiehemme, Aadolf
Erik Nordenskiöld, on antanut sille nimen sordavaliitti. Sordavaliittia
ei tietenkään ole tavattu missään muualla kuin siinä kalliossa, jonka
päälle Sortavalan lutherilainen kirkko on rakennettu.
Sortavalan ja Impilahden pitäjistä viedään paljon feltspaattia ja

kvartsia Wenäjälle. Parolan kylä Sortavalan saaristossa on tunnettu
harvinaisen suurista turmaliinikiteistään, joita siellä tapaa feltspaatti-
kivessä. Sortavalassa löytyy grafiittiakin. Yhteen aikaan vietiin sitä
paljon Wenäjälle, toisin vuosin 40,000 leiviskään. Sitä käytettiin siellä
asfalttihuovan valmistamiseen. Nyt on se vienti kokonaan loppunut.
Kansa näkyy entisinä aikoina käyttäneen tuota veitsellä helposti

vuoltavaa mineraalia kaikenlaisiin pieniin tarpeisiin, päättäen niistä
grafiitista tehdyistä tulusneuvojen "rikkikupeista", koristuksien
valimista y.m., joita talletetaan Sortavalan kaupungin museossa.
Suuressa maineessa olivat entiseen aikaan Kitilän granaatit.
Kuningas Juhana III, jonka sotapäällikkö Pontus de la Gardie v. 1580
oli valloittanut Käkisalmen linnan ja läänin, kirjoittaa sikäläisille
voudeilleen, että heidän piti kerätä ja lähettää Ruotsiin noita
"Käkisalmen rubiineja" ("the Kexholmische rubijner"). Niitä
lähetettiinkin hänelle tynnyreittäin ja Juhana kuningas lienee toivonut
saavansa oikein rikkaankin aarreaitan haltuunsa, kunnes tietysti
asiaa tarkemmin tutkittaissa huomattiin, ett'eivät Kitilän
punahohtoiset granaatit olleetkaan todellisia jalokiviä.
Tämän yhteydessä kerrottakoon helmenpyynnistä, jota

harjoitetaan muutamin paikoin Itä-Karjalassa. Kuten tiedetään, ovat
helmet jonkunlaisia kasvannaista tai taudillisia ilmiöitä helmiraakussa
(Unio margaritifer). Arvellaan niiden syntyvän siten, että eläimen
ruumiiseen tunkeutuu joku pieni hiekkakaunainen tai muu vieras
kappale. Se aikaansaapi ärsytyksen ja eläin erittää silloin
ruumiistaan peerlemoriainetta, joka kerrostuu tuon vieraan esineen
ympäri. Helmiraakku elää joskus järvivesissä, mutta parhaiten se
näkyy viihtyvän kivikkopohjaisissa puroissa, missä vesi virtaa
nopeasti eteenpäin. Raakku seisoo aina pystyssä, osa eläintä ulkona
kuorestaan, pohjamutaan imeytyneenä. Suurimmat raakut ovat noin
13 sentimetrin pituisia.
Impilahden pitäjässä ovat Ruokojärvi ja Laatokkaan laskeva

Liimonoja tunnettuja helmenpyynti-paikkoja. Liimonojassa, jossa
tämän kertoja on käynyt helmiä pyytämässä, löytyy raakkuja
runsaasti. Parissa tunnissa voipi yksi henkilö helpolla vaivalla poimia
niitä useampia satoja. Kun on kerätty tarpeeksi raakkuja purosta, niin
alkaa itse helmien hakeminen. Se on vastenmielistä työtä,
jonkunlaista joukkoteurastusta. Raakun kuoripuoliskot kiskotaan näet
puukolla irralleen toisistaan ja eläin tietysti silloin kuolee. Toisinaan
saapi avata satoja raakkuja, ennenkuin onnekseen sattuu helmen
löytämään.
Kansa Impilahdella on oppinut panemaan arvoa helmille ja niitä

pyytämään. Joskus saapi pyytäjä hyvänkin päiväpalkan, jos löytää
kauniita ja suuria helmiä. Kirkkaista, isoista helmistä maksavat
kultasepät kymmeniä markkoja kappaleesta. Mustia ja ruusunvärisiä
helmiä sanotaan kallisanvoisimmiksi. Suomen yleisessä teollisuus-
ja taidenäyttelyssä Helsingissä v. 1876 oli valikoima Impilahden
helmiä näytteillä.
Kansalla on se luulo, että pian jokaisessa raakussa löytyy helmiä,

mutta että eläin tavallisesti sylkäsee ne ulos, kun sitä tullaan
kiinniottamaan. Tämän kertoi viime kesänä Liimonojan varrella
asuva mylläri, vanha, tottunut helmenpyytäjä. Oli sillä ukolla monta
muutakin tarinaa. Muun muassa kuuluvat sorsatkin helmiä pyytävän.
Kirkkaalla säällä avaa raakku kuorensa, "päiveä paistattaapi." Sorsa
lentää ilmassa, näkee kirkkaan Helmen kimmeltävän
auringonpaisteessa: "kynnel koabasov dai suuh noblahuttav."
[Kynnellä kaapasee ja suuhunsa nielasee.] "Ulkomailla" on muka
ammuttu sorsia, joiden kuvusta on löydetty helmiä. Ja niin oli ukko
mylläri vakuutettu tarinansa todenperäisyydestä, ett'ei yritettykään
sitä kieltää.
On muuten omituista nähdä, miten nuo vanhat tarut vaeltavat.

Tunnetun historioitsijan ja kansantapojen kertojan, Olaus
Magnuksen teoksessa "Pohjoismaisten kansojen erilaisista tavoista",
joka ensi kerta painettiin Roomassa v. 1555, esitetään eräässä
kuvassa helmenpyyntiä. Siinä nähdään muun muassa, miten raakku
avaa kuorensa, "päivää paistattaakseen", ja sorsa leijuilee ilmassa,
tähystellen sen sisässä olevaa helmeä. Tästä näkyy, että tuo sama
tarina jo oli olemassa neljättäsataa vuotta sitten ja että sen ajan
oppineetkin sitä uskoivat.
Wärtsilän rautaruukki on Karjalan ja samalla koko maamme

suurimpia teollisuuslaitoksia. Sen perusti v. 1850 tunnettu ja
ansiokas suurteollisuuden edistäjä Niilo Ludvig Arppe. Ruukki
sijaitsee Tohmajärven pitäjässä pienen Juvanjoen varrella, joka
Suurjoen kautta laskee Jänisjärveen.
Wärtsilän rautaruukkiin kuuluu monenlaisia laitoksia. Masuunissa

valmistetaan suorastaan rautamalmista n.s. takkirautaa.
Putlauslaitoksessa melloitetaan takkirauta n.s. melto- eli
kankiraudaksi; valssilaitoksessa puristetaan meltorauta kangiksi.
Walurautaa ja valuterästä valmistetaan n.s. martinlaitoksessa ja sen
yhteydessä olevassa harkkouunissa. Edelleen kuuluu Wärtsilän
ruukkiin konepaja ja valimo.
Möhkön ja Läskelän ruukit, edellinen Ilomantsissa, jälkimmäinen

Sortavalassa, ovat niinikään Wärtsilän yhtiön omia. Möhkössä on
kaksi masuunia, Läskelässä taepaja, kaksi sahaa ja suuremmoinen
myllylaitos.
Wärtsilän ruukki ottaa sulatettavan rautamalminsa noin 50

järvestä: Tohmajärven, Pälkjärven, Korpiselän, Suistamon, Kiteen,
Kiihtelysvaaran, Ruskealan ja Uukuniemen pitäjissä. Raa'asta
järvimalmista tehdään rautan seuraavalla tavalla. Malmi pannaan
masuuniin, joka on korkea, kirnuntapainen laitos. Masuuniin
kaadetaan hiiliä polttoaineeksi. Hehkuvien hiilien kovassa
kuumuudessa sulaa malmi vähitellen ja valuu masuunin pohjaan.
Sula rauta lasketaan määräajalla pois ja masuuniin kaadetaan lisää
malmia ja hiiliä. Täten saatua rautaa sanotaan takkiraudaksi.
Wärtsilässä on viime aikoihin valmistettu noin 2,500,000 kgr.
takkirautan. Nyt aijotaan valmistusta lisätä.
Möhkössä on, kuten mainittiin, kaksi masuunia takkiraudan

valmistamista varten. Kaikki siellä sulatettu takkirauta viedään
Wärtsilään. Talvella on Wärtsilän ja Möhkön välisellä taipaleella ja
yleensä sen puolen saloteillä vilkas rahtiliike. Pitkissä jonoissa
kulkevat rahtikuormat verkkaan eteenpäin, mikä vieden malmia
Möhköön, mikä taas valmista takkirautaa Wärtsilään. Miehet
kulkevat tavallisesti yhdessä ryhmässä hevosten perässä. On siellä
aikaa pakinoida, eräskin piipullinen polttaa.
Takkiraudasta valmistetaan melto- eli kankirautaa siten, että siinä

löytymä hiiliprosentti alennetaan. Tämä tapahtuu n.s.
putlausuunissa. Sieltä otettu tulikuuma rautamöhkäle pannaan
suuren höyryvasaran alle ja taotaan muutamalla iskulla harkoksi.
Tämä harkko pannaan taas kulkemaan likistimien eli valssien väliin
ja puristetaan niissä erikokoisiksi kangiksi.
Järvi- ja suomalmissa on suurena haittana fosfori, joka tekee

raudan ja eritenkin teräksen kylmässä hauraaksi. Toistakymmentä
vuotta sitten tehtiin Englannissa keksintö, jonka kautta fosfori saatiin
eroitetuksi raudasta paremmin kuin siihen asti käytetyillä keinoilla.
Ruvettiin näet rakentamaan sulatusuuneja, jotka sisästä olivat
vuoratut sellaisella kivellä, joka raudan sulaessa kemiallisesti
yhdistyy fosforin kanssa, eli toisin sanoen vetää fosforin puoleensa.
Wuonna 1884 alettiin Wärtsilässä tämän keksinnön käyttämiseksi

rakentaa n.s. Martin-uunia ynnä siihen kuuluvia laitoksia. Hallitus
myönsi tarkoitusta varten 60,000 markan lainan edullisilla ehdoilla.
Seuraavana vuonna olivat uudet sulatuslaitokset valmiit. Kivilajit,
joita käytetään näissä sulatusuuneissa fosforin eroittamiseksi, ovat
dolomiitti ja kalkkikivi. Kumpaistakin löytyy verrattain lähellä
Wärtsilän ruukkia: kalkkikiveä Ullamonvaarassa Pälkjärvellä ja
dolomiittia Tohmajärvellä.
Raudan sulatukseen tarvittavat hiilet ruukki osaksi polttaa omissa

sysimiiluissaan, osaksi ostaa ne valmiina ympäristön talonpojilta. On
koetettu käyttää suomutaakin polttoaineena. Mutta puuta on
tehdasyhtiöllä kyllin kylliksi. Se omistaa näet iloin 250,000
tynnörinalaa metsäistä maata. Suurin osa yhtiön metsistä on
Ilomantsin pitäjässä. Ne täyttävät suuremman alueen kuin moni pieni
ruhtinaskunta Saksassa.
Wärtsilän tehdas maksaa vuosittain ulos noin 711,000 markkaa

työpalkoissa, raaka-aineiden ostoon y.m. Tuhansille ihmisille hankkii
se välitöntä työtä tai välillistä ansiota. Suurin osa tehtaan tuotteista,
takkirautaa ynnä terästä, on, epäedullisista tullisuhteista huolimatta,
viety Wenäjälle. Walmiiksi valetut ja taotut tavarat myödään
enimmäkseen omassa maassa.
Wärtsilän tehdas on niinkuin pieni kaupunki. Työväkeä on siinä

noin 500:aan ja koko asukasluku nousee noin 900:aan. Tehtaalla on
oma kirkkonsa ja kaksi kansakoulua. Työväen henkistä ja aineellista
etua edistää tehdasyhtiö kiitettävällä tavalla. Työväellä on siellä
kirjastonsa, lukusalinsa, säästö- ja apukassansa.
Karjalan radan valmistuttua koittaa Wärtsilälle varmaankin

edullisemmat ajat. Karjalan emäradasta on sivurata vedetty
tehtaaseen. — Onnea toivoo jokainen suomalainen tälle mahtavalle
suurteollisuuslaitokselle, joka Karjalan takamailla satoja koteja
elättää, tuhansien kansalaisten toimeentuloa turvaa.
Merkillisimpiä paikkoja Karjalassa on Pitkänrannan vaskikaivos.
Se sijaitsee Impilahden pitäjän itäkulmalla, aivan Laatokan rannalla.
Wuonna 1810 havaittiin ensi kerran, että vaskimalmia löytyi
Pitkänrannan vuorissa. Tämä löytö ei kuitenkaan herättänyt sen
suurempaa huomiota, sillä asiantuntijat selittivät, ett'ei louhostyö
kannattaisi. Neljä vuotta myöhemmin ruvettiin kuitenkin malmia
louhomaan, mutta työ seisahtui pian tarpeellisen yrittelijäisyyden ja
pääoman puutteessa.
Wuonna 1820 joutui Pitkäranta englantilaisen Lionel Lukin'in

haltuun. Hän valtasi sen ynnä 13 muuta malmiaihetta Impilahden ja
Suistamon pitäjissä. Lukin oli tarkasti tutkinut näiden seutujen
kivennäisluontoa. Hän oli siellä löytänyt vaskea, tinaa,
hopeanpitoista lyijyä, sinkkiä ja grafiittia. Toivoi kivihiiliäkin löytyvän.
Wuonna 1821 teki Lukin hallitukselle ehdoituksen Pitkänrannan

malmirikkauksien käyttämisestä. Oli muodostettava suuri yhtiö, joka
toimisi hallitsijan erityisen suojeluksen alaisena. Yhtiön pääoma oli
kerrassaan laitettava hyvin suureksi, yhdeksi miljoonaksi ruplaksi,
jaettuna 1,000 ruplan osakkeihin. Yhtiö saisi omistusoikeuden
kaikkiin malmiaiheisiin kuuden peninkulman laajuisella alalla ynnä
täyden käyttöoikeuden kaikkiin tällä alueella oleviin vesistöihin ja
halkometsiin. Liikevoittoa kuvaili Lukin erittäin edulliseksi: "vähintäin
25 prosentiksi, varmaankin 50:si, luultavasti 100:si, mutta
mahdollisesti 500 prosentiksi pääomasta." Hallitus suostui Lukinin
pyyntöön ja antoi hänelle nuo anotut etuoikeudet. Mutta tuosta
suuresta yhtiöstä ei kuitenkaan tullut mitään. Ei näet saatu
tarpeellista osake-pääomaa kokoon. Lukin sentähden menetti
oikeutensa, kun ei työtä voitu panna alkuun.
Tällaisessa lepotilassa oli sitten Pitkänrannan kaivos 11 vuotta,
kunnes sen uudestaan valtasi eräs Omeljanov niminen venäläinen.
Hän alkoi oikein todenteolla vuorta louhoa ja käytti siihen koko
omaisuutensa. Mutta syystä tahi toisesta ei hänkään menestynyt ja
luopui yrityksestä, tehtyään vararikon. Pitkänrannan kaivos myötiin
julkisella huutokaupalla ja joutui Impilahdesta kotoisin olevalle Judin
nimiselle talolliselle. Hän möi sen vuorostaan kaivoksen entiselle
työnjohtajalle Joffriaud'ille. Wuonna 1879 joutui Pitkäranta nykyisille
omistajilleen, ruotsalais-venäläiselle pankkiirifirmalle Meyer &
Winberg'ille.
Näin oli Pitkänrannan kaivos kulkenut kädestä käteen. Jokainen

sen omistajista oli jatkanut edeltäjänsä työtä, mutta ei kukaan ollut
siinä oikein onnistunut. Suurimpana haittana oli ollut riittävän liike-
pääoman puute. Wasta nykyisten omistajiensa käsissä on Pitkäranta
tullut suureksi teollisuuslaitokseksi, joka käyttää satoja ihmisiä
palveluksessaan.
Pitkänrannan kaivoksesta saadaan etupäässä vaskea, mutta

myöskin vähemmässä määrässä tinaa ja hopeata. Tämän lisäksi
löytyy siellä kätkettynä maan poveen mitä erilaisimpia metalleja ja
mineraaleja. Siellä on sinkkiä, lyijyä, grafiittia, rikkikiisua ja
monenlaatuisia kauniita mineraalikiteitä, niinkuin punaisia
granaatteja, läpikuultavia, vesikirkkaita vuorikristalleja j.n.e. Kaivos-
alueella löytyy useampia kaivoksia. Syvin niistä johtuu 600 jalkaa
maanpinnan alle.
Ennenkuin uutta kaivotta ruvetaan tekemään, täytyy tietysti ensin

tutkia, missä ja kuinka malmisuonet kulkevat. Tämä tapahtuu
omituisella tavalla, n.s. timanttiporan avulla. Porana käytetään
rautaputkea, jonka alareunaan on kiinnitetty timantteja. Timantin
edessä ei kestä kallio enempää kuin pehmeät maakerroksetkaan.
Kun pora pannaan pyörivään liikkeeseen, syöpyy rautaputki tuota
pikaa vuoren sisään. Kun se on uponnut oman mittansa, kierretään
sen päähän toinen, samanlainen putki ja tällä tavalla voidaan sitten
jatkaa vaikka satoja jalkoja alaspäin. Rautaputkiston onttoon
sisustaan jääpi tietysti sydän osoittamaan sen vuori- tai
maakerroksen laatua, jonka läpi pora kulloinkin on kulkenut.
Woidaan siis nähdä niinkuin kartasta ainakin, minkälaatuista on
maan sisusta sillä tai sillä syvyydellä.
Kun viimein on malmisuoni löytynyt, niin tutkitaan sen suunta,

laajuus ja paksuus uusilla porauksilla. Wasta näiden valmistavien
toimien jälkeen alkaa varsinainen kaivostyö. Louhominen tapahtuu
dynamiitilla. Jos malmisuoni on syvemmällä, täytyy vuorta särkeä
hyvinkin kauan, ennenkuin päästään malmiin käsiksi. Uutta kaivosta
tehtäessä täytyy menetellä varovaisesti ja määrätyn suunnitelman
mukaan. Täytyy näet jättää tarpeeksi paljon ja tarpeeksi vahvoja
tukipylväitä louhosholvien kattoja kannattamaan. Itse kaivos on
jaettu moneen osaan ja kerrokseen. Eri kerroksia yhdistää toisiinsa
aukot ja kapeat käytävät.
Tuntuu niin omituiselta, kun ajaen lähestyy Pitkänrannan tehdasta,

ja kyytimies sanoo, että nyt sitä jo kuljetaan ontolla maanpinnalla.
Tuolla synkässä syvyydessä, satoja jalkoja maantien alla,
työskentelee himmeiden lamppuliekkien valossa ahkera ihmisparvi,
loitsien esiin maanemän rikkauksia. Ja täällä ylhäällä paistaa niin
kirkkaasti Luojan lämmin päivä, taivaan laki näyttää niin kauniin
siniseltä ja ruohoinen tienvieri niin eloisan viheriältä.
Saavuttuamme perille, koetamme tietysti päästä kaivoksia

katselemaan. Meille annetaan joku työnjohtaja oppaaksemme ja
tämä viepi meidät siihen paikkaan, mistä on sopivinta laskeutua alas
syvyyteen. Warovaisinta on sitä ennen pukea toiset, huonommat
vaatteet päälleen, sillä kovasti sitä rähjääntyy ja ryvettyy,
kaivosportaita astuessa. Opas ottaa tulisoihdun käteensä ja antaa
samanlaisen vieraalle. Soihtu on tehty pikkusormen paksuisista
tervasliisteistä, jotka ovat toisiinsa kiinnitetyt rautavanteella. Se
kestää hyvin toista tuntia, jos sitä pitää pystyisessä asemassa
tulenliekki ylöspäin.
Näin varustettuna sitä nyt lähdetään astumaan alas kaivosportaita

myöten. Portaat ovat tavallisia tikapuita, joiden astelmat joskus ovat
raudasta, mutta enimmäkseen puusta tehdyt. Tikapuut kulkivat
ainakin siinä kaivoksessa, jota tämän kertoja kävi katsomassa, aivan
kohtisuoraan alaspäin. Kymmenisen sylen perästä saavutaan
pienelle, puiselle lavalle, jonka sivulta aukeaa toinen aukko, johtaen
seuraavaan kaivosholviin. Tästä aukosta tullaan samanlaisia
tikapuita pitkin kolmannelle lava-alustalle, sieltä neljännelle j.n.e.,
yhä alaspäin pilkko pimeässä syvyydessä. Tulisoihdukkaan eivät
valaise kuin lähintä ympäristöä.
Astuminen noita kohtisuoria tikapuita myöten on hieman vaikeata.

Ensiksikin täytyy kaiken aikaa kiivetä vaan yhden käden varassa,
kun tulisoihtu on toisessa kädessä. Toiseksi ovat tikapuiden astelmat
aivan paksussa, tahmaisessa savivellissä, sillä ilma alhaalla
kaivoksessa on kosteata ja vettä tippuu lakkaamatta kattoholveista ja
tihkuu seinien raoista. Täytyy olla hyvin varoillaan astuessa, ett'ei
luiskahda, sillä silloin voisi suistua tiesi kuinka syvälle ja
murskaantua. Toisiin kaivoksiin on pääsö helpompi, niihin kuin johtaa
oikeat rappuportaat tai hinauslaitokset. Eräissä kohdin hinaavat
työmiehet itsensä alas suurissa tynnöreissä.
Kaivoksissa on ilma kylmänviileätä. Sormet oikein pyrkivät
kohmettumaan. Erittäin mahtavalta ja juhlalliselta kuuluu
dynamiittilaukaus tuolla alhaalla. Kumea ääni jyskää kuin kovin
ukkonen holvista holviin, käytävästä käytävään. Koko kaivos tärisee.
Joskus sattuu kivilohkare irtautumaan jonkun holvin katosta tai
seinästä ja silloin on hengenvaara lähellä alla olijoille.
Kaivoksen pohjalla kulkee rautainen kiskotie louhotun malmin

kuljettamista varten nostoaukolle. Malmivaunut työnnetään kiskoja
pitkin miesvoimalla. Louhostyössä ilmestyy tietysti hyvin paljon
kelpaamatontakin tavaraa. Nämä malmista köyhät kivet pannaan
erikseen ja kuljetetaan sellaisiin käytäviin, joissa ei enää louhota.
Käytävät täytetään kattoaan myöten ja suuret onsikohdat saadaan
siten täyteläisiksi ja kestäviksi kannattamaan ylempänä olevien
kerroksien raskasta painoa. Joka kaivoksessa löytyy edelleen
pumppulaitoksia, jotka lakkaamatta ovat käynnissä. Tämä on
välttämätöntä, sillä muuten täyttyisi kaivos pian vedellä.
Pumppulaitosta käytetään maan päällä olevien höyrykoneiden
avulla.
Maanpinnalle nostettu malmi lajitellaan ensin tarkasti, jotta

saataisiin köyhimmät kivimöhkäleet pois eroitetuiksi. Kelpaava malmi
viedään sitten valssilaitokseen. Wahvojen teräsvalssien välissä
musertuvat kovat kivimöhkäleet aivan kuin olisivat sokuripaloja vaan
ja muuttuvat jauhoksi. Tämän jauhon sekaan survotaan keittosuolaa.
Tämän perästä alkaa kelpaavan, puhtaan metallin eroittaminen

malmijauhosta. Se tapahtuu osaksi tulen avulla, osaksi
monimutkaisten kemiallisten prosessien kautta. Emme huoli tätä
menettelyä tarkemmin seurata. Se vaan mainittakoon, että
malmijauho pannaan suuriin, hapoilla täytettyihin ammeisiin, joissa
puhdas metalli vähitellen erkanee niistä aineista, joihin se on ollut
yhdistettynä. Tähän liuentamiseen käytetään muun muassa rautaa.
Pitkänrannan tehdas ostaa sentähden vuotuisesti suuret määrät
romurautaa.
Kun puhdas metalli viimein on eroitettu, jäävät muut aineet

tähteinä jälelle. Nämä kuonatähteet eivät sentään joudu hukkaan,
vaan niitäkin käytetään. Sellaista tähdekuonaa on esim.
rautakloruuri. Tätä ainetta sisältävä liuos sekoitetaan savella ja seos
poltetaan punamullaksi. Pitkänrannan tehdas voipi täten valmistaa
niin paljon punamultaa, että sitä olisi koko maamme tarpeeksi.
Toisista tähdeaineista saadaan lasia. Pitkässärannassa onkin
kaivosteollisuuteen yhdistetty sunrenlainen lasinvalmistus. Tehtaan
sulatusuunit voivat tarvittaessa valmistaa 3—4 miljoonaa lasipulloa
vuodessa. Tätä viimeksi mainittua tavaraa viedään milt'ei
yksinomaan Wenäjälle ja on sillä viime aikoina ollut hyvä menekki.
On muuten hauskaa katsella lasinpuhaltajia, kun he ovat

työssään. Pitkässä jonossa seisovat he uuniensa edessä, liikutellen
puhallusputken päässä olevaa tulikuumaa, sulaa lasimöhkälettä.
Tuossa tuokiossa on pullo valmiiksi puhallettu ja valettu. Pullon
ontevuus syntyy näet puhaltamalla, sen ulkomuoto taas erityisissä
valimissa. Pieniä poikia, puiset kaukalot käsissä, juoksee
edestakaisin lasiuunien edustalla, ottaen vastaan valmiiksi puhalletut
ja muodostetut pullot puhaltajilta. Pullot viedään erityiseen kuumaan
uuniin, jota vähitellen jäähdytetään. Täten tulevat pullot kestäviksi ja
estyvät paikalla särkymästä. Lasin puhaltaminen on raskasta työtä ja
vaatii terveitä keuhkoja. Tuskin siinä työssä pitkäikäiseksi pääsee.
Tuo tavaton kuumuus uunin ääressä mahtaa olla hirveän rasittava.
Aivan tehtaan edustalla löytyykin ryöppykylpylaitos, jossa
lasinpuhaltajat kesäiseen aikaan käyvät vilvoittelemassa. Ainakin
kerta tunnissa juoksevat he vesisuihkun alle — täysissä vaatteissa ja
tamineissa. Läpimärkinä palaavat he takaisin työhönsä ja tuota pikaa
ovat heidän vaatteensa rutikuivat. Tätä menoa jatkuu pitkin päivää.
Se ei mitenkään saata olla terveellistä. Mutta raataja rahanalainen,
ei hän jouda katsomaan, mikä on terveellistä, kun on iso perhe
raskaalla työllä elätettävä. Toinen, onnellisemmassa tilassa elävä
ihminen käyttää hänen työnsä tuotteita, ajattelematta ja tuntematta
palvelevaa veljeä, joka saapi päivän raskauden kantaa, sen hiet
kestää.
Pitkänrannan tehdas tuotti v. 1685,456,000 naulaa puhdasta

vaskea, 34,400 naulaa tinaa ja 1,220 naulaa puhdasta hopeaa.
Tehtaan työväki nousee noin 600 henkeen ja tehdasalueella asuu
toistatuhatta ihmistä. On kuin pieni kaupunki konsanaankin.
Tehtaalla on oma kansakoulunsa, oma pappinsa, oma lääkärinsä ja
oma sairastalonsa. Paljon on siellä ulkomaalaisiakin: ruotsalaisia,
saksalaisia ja venäläisiä.
Kaikesta huomaa, että Pitkäranta jo sijaitsee kansallisuutemme

rajamailla.
Pitkärannasta ei ole kuin pieni pyöräys rajalle. Poikkeamme rajan

toiselle puolelle, esim. Aunuksen kaupunkia eli "Anuksen linnaa"
katsomaan. Tuollainen matka voipi monessakin suhteessa olla
hauska ja opettavainen.
"Anuksen linnu" sijaitsee noin 60 kilometria Suomen rajalta. Sinne

vievä maantie kulkee tasaista hiekkakangasta myöten. "Doroga" [tie]
on pehmeä ja pölyinen, kerrassaan luonnonvoimien vallassa. Ei
"kohenneta" [korjata] niinkuin Suomen puolella. Luonto on aivan
toisenlainen kuin Suomessa. Ei missään näy noita jyrkkiä,
metsärinteisiä vaaroja, jotka tekevät Sortavalan ja Impilahden
maisemat niin kauniiksi. Ei myöskään näy mitään saaristoa.
Rannasta aukeaa kohta Laatokan aava ulappa.
Aunuksen kaupunki sijaitsee keskellä viljavaa tasankoa, jota

sanotaan
"Anuksen augiekse." Tämän tasangon halki juoksee kaksi pientä
jokea:
Mägreän ja Yllösenjoki. Noin parikymmentä kilometriä Laatokasta
yhtyvät
ne n.s. Alvoshen-joeksi. Tässä niiden yhtymäpaikassa on "Anuksen
linnu."
"Anuksen augie" on tiheimmin asuttu seutu koko Wenäjän-

Karjalassa. Siellä on kylä kylän vieressä, ett'ei niiden välillä ole kuin
neljännes, korkeintaan puoli kilometriä. Rakennukset noissa kylissä
ovat pyöreistä hirsistä, enimmäkseen tuota Wenäjän-Karjalassa
tavallista mallia.
"Anuksen linnu" ei suuresti eroa ympäristön maakylistä.

Senpävuoksi onkin, siinä missä kaupunki alkaa, pystytetty patsas ja
siihen kiinnitetty puutaulu, jossa venäjänkielellä ilmoitetaan, että
tässä se nyt on Aunuksen kaupunki. Taulu on siis samalla
jonkunlaisena Vaedeker'inä eli matkaoppaana, sillä siinä ilmoitetaan
muun muassa sekin seikka, että kaupungissa on noin 150 taloa ja
asukkaita noin 700 vaiheilla.
Kaupungissa ei huomaa merkkiäkään asemapiirroksesta. Kadut,

eli paremmin sanoen, ajotiet kulkevat ilman mitään järjestystä ja
niiden varsille ovat talot rakennetut, noin sikin sokin vaan, pääty
kadulle päin. Julkisista rakennuksista mainittakoon kolme venäläistä
kirkkoa, joista yksi kivinen, sotaväen kasarmi, vankila eli "tyrmä",
sairastalo ja kaupungin koulutalo. Lutherinuskoisilla suomalaisilla on
täällä pieni rukoushuone.
"Anuksen linnan" varsinaiset asukkaat eli "rahvas" ovat järjestään

karjalaisia. "Herrat" eli virkamiehet ovat venäläisiä.
"Rahvas" puhuu "Livvin kieldy", s.o. Aunuksen-Karjalan murretta.

Kauppiaatkin käyttävät omassa keskuudessaan tätä kieltä. Kaikki
osaavat he kuitenkin venäjänkieltä, ken paremmin, ken huonommin.
"Herrat" eli säätyläiset puhuvat keskenään venäjää. "Maltetah i

herrat livvikse paishta." [Herratkin osaavat puhua Aunuksen-Karjalan
murretta.] Ei auta muu kuin malttaminen näin suomalaisen väestön
keskuudessa. "Herroja" ei muuten ole paljon. Heistä mainittakoon
tietysti ensimmäisenä kaupungin poliisimestari eli "ispravniekka."
Kunnia sille, jolle kunnia tulee. Sitten seuraa luettelossa muutamia
upsierejä, pari lääkäriä, posttmestari, "golova" eli kaupungin
valtuuskunnan esimies, papit ja koulumestari.
Elämäntavat ovat yksinkertaisia. Kaupungin porvarit eli "rahvas"

elävät kerrassaan samaa elämää kuin ympäristön talonpojat. Hyvin
suosittuna teollisuutena on heillä vesirinkelien leipominen. Näitä
rinkeliään kuljettavat "Anuksen linnan" asukkaat suuret määrät
Suomen puolelle markkinasta markkinaan.
Säätyhenkilöiden seurustelutavat ovat yhtä yksinkertaisia.

Pistäytään milloin toisen, milloin toisen luo pakinoimaan päivän
tapauksista, ilmasta y.m. — Andrej Petrovitsch on ostanut itselleen
uuden turkin, Iivan Stepanovitsch vaihtanut vanhan hevosensa
uuteen ja parempaan. Ja siinä se menee pieni viinaryyppykin mukiin
puheen jatkona noin aamusta päivin. Iltaa istutaan vhistipöydän
ääressä.
Kirjapainoa ei löydy, ei sanomalehtiä, ei päivän polttavia
kysymyksiä eikä puolueita. Teknillisten keksintöjen alalla ovat
"Anuksen linnan" asukkaat tänä höyryn aikakautena käyttäneet
hyväkseen ainoastaan tuon perin venäläisen keksinnön
"samovaarin."
Palaamme takaisin rajan yli. Tulemme Sortavalan kaupunkiin.
Sortavala on Suomen puoleisen Raja-Karjalan henkisenä ja

aineellisena keskuksena.
Kaupungilla on kaunis asema Laatokan rannalla. Sen vastapäätä

oil suuri Riekkalan saari korkeine vuorineen. Mannermaankin
puolella kohoaa useampia vuoria ja niiden välissä on pieniä järviä:
Airanne, Hympylän- ja Liikolanjärvet. Wakkolahti jakaa kaupungin
kahteen osaan: vanhaan, jota tavallisesti nimitetään "Kaupungin
puoleksi", ja uuteen eli "Kymölän puoleen." Niitä yhdistää toisiinsa
pitkä kävelysilta. Uuden kaupunginosan luonnollisena jatkona on
Kymölän seminaarin alue koulurakennuksineen.
Sortavalan kaupunki on "niitä esivallan pienimpiä." Siinä on vaan

1,300 asukasta. Rakennustapa on samanlainen kuin maamme
muissakin pikkukaupungeissa. Wähänkin varakkaammilla perheillä
on koko talo omassa hallussaan. Talon yhteydessä on tavallisesti
pieni puutarha tai ainakin vähän istutuksia. Julkisista rakennuksista
mainittakoon kaupungintalo. Se on hyvin sievä, tunnetun
rakennustaiteilijamme Sjöström'in piirustuksen mukaan rakennettu.
Siinä löytyy pieni historiallis-kansatieteellinen museo, johon on
koottu Itä-Karjalan muinaisuutta ja nykyistä kansanelämää valaisevia
esineitä, muun muassa muutamia satoja kivikauden aseita ja
työkaluja.
Kaupungin laidassa on Wakkosalmen puisto. Yhdeltä puolelta
rajoittaa sitä puoliympyrässä Airanteen järvi, toisella puolella pieni
Wakkojoki, jota myöten viimeksi mainitun järven vesi laskee
Laatokkaan. Kaunis Kuhavuori sijaitsee osaksi puiston alueella.
Sieltä on erittäin kaunis näköala. Itäisellä ilmansuunnalla kohtaa
silmä laajan, keskeytymättömän metsämaiseman, jota korkeat
vuoret etäällä reunustavat. On kuin seisoisi Raja-Karjalan salojen
kynnyksellä ja Kirjavalahden vaaroilta nouseva kaskensavu tekee
mielikuvituksen vielä täydellisemmäksi.
Kuuluu kimakka vihellys, joka silmänräpäyksessä muuttaa

tunnelman toisenlaiseksi. Waistomaisesti kääntyy silmä ääntä
hakemaan ja näkee, kuinka höyryveturi kiitää tekosärkkää pitkin
Wakkolahden poikki, pitkä jono tavaravaunuja perässään.
Siellä se nyt on Karjalan rata, tuo kauan kaihottu, hartaasti

toivottu! Tuokoon se uutta vireyttä Karjalan takamaille, vilkkaampaa
henkistä yhteyttä muun Suomen kanssa!
Sortavala on tärkeä koulukaupunki. Paikkakunnan suurin

oppilaitos on Kymölän opettajaseminaari. Seminaarin edelläkävijänä
oli n.s. Siitosen koulu, jonka puolisot Herman ja Elisabet Hallonblad
perustivat Kymölä nimiselle maatilalleen lähelle Sortavalan
kaupunkia.
Siitosen koulu alkoi toimensa v. 1864 ja jatkoi sitä hyvällä

menestyksellä vuoteen 1880. Se oli jonkinlaisena kansakoulun ja
kansanopiston välimuotona. Opettajavoimat olivat erittäin hyvät ja
oppilaita oli runsaasti.
Myöhemmin heräsi Siitosen koulun perustajissa ajatus, että

heidän koulunsa oli muutettava opettajaseminaariksi. He tarjosivat
koko Kymölän suuren maatilan ynnä 360,000 markan pääoman
Suomen valtiolle, jos valtio ottaisi perustaakseen opettajaseminaarin
Sortavalaan. Wuoden 1879 valtiopäivillä ottivat Waltiosäädyt tarjotun
lahjan vastaan ja Karjala sai seminaarinsa. Uusi oppilaitos alkoi
toimensa v. 1880 ja Siitosen koulu lakkasi.
Sortavalan seminaarin merkitystä on tarpeetonta kuvata

suomalaiselle lukijalle. — Paitsi seminaaria on Sortavalassa tätä
nykyä olemassa kuusiluokkainen suomenkielinen tyttökoulu,
viisiluokkainen, suomenkielinen poika-lyseo, merimieskoulu ynnä
kutoma- ja käsityö-koulu, jotka kaikki nauttivat valtioapua.
Sortavalassa tehdään paljon ja innokasta työtä Raja-Karjalan

kansan kohottamiseksi. Ja kansan taajat rivit alkavat jo tuota työtä
huomata, alkavat käsittää sen tekijöitä luotettaviksi ystävikseen.
Sortavala ja "Anuksen linnu" ovat kaksi vanhaa, perin karjalaista

pikkukaupunkia. Ja kuitenkin ovat ne niin erilaisia.
Mistähän sekin tulee?
Toinen Luku.
Salomailla.
"Metsän onni, metsän Osmo

Pane juoni juoksemahan
Näillä mailla, manterilla,
Näillä miehen metsimailla,
Näillä harhoilla saloilla.

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Pediatric Education for Prehospital

Professionals PEPP Fourth Edition

Pediatric Telehealth Best Practices American Academy Of

Coding for Pediatrics 2022: A Manual for Pediatric

Pediatric Collections Sports Medicine Playbook 1st

Depression and Suicide Prevention Pediatric Collections

Coding for Pediatrics 2023 A Manual for Pediatric

The American Academy of Pediatrics Guide to Toilet

Ethics Rounds a Casebook in Pediatric Bioethics 1st

ECigarettes 1st Edition American Academy Of Pediatrics

Copyright © 2021 by the American Academy of Pediatrics.

9781284238266_FMxx_Final.indd 2 24/08/21 12:19 PM

Chapter 16 Transportation Considerations. . . . . . . . . . . . . . . . . . . . . . . . 307

Management of Acute Respiratory Cardiac Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Summary of Primary Assessment . . . . . . . . . . . . . . . . . 152 Children Assisted by Technology. . . . . . . . . . . . . . . . . . 199

SUID Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 Child Restraint Systems in Ambulances . . . . . . . . . . . 310

Chapter 15 Medicolegal and Ethical Procedures�����������������������������������������������������������335

17 Intraosseous Needle Insertion��������������������������������� 409 24 Removing and Replacing a

PEPP Steering Committee

Brandon Kelley, NRP Toni M. Petrillo, MD, FAAP

Mary Otting, RN, BSN, CEN Michael J. Stoner, MD, FAAP

EMS Reviewers Jeffery D. Gilliard, FPM/CCEMTP/NRP

In celebration of the 20th Anniversary of the PEPP

Prevention involves professionals recognizing the

Pediatric Assessment Triangle (PAT)

Evaluating the setting includes an inspection of

FIGURE 1-2 Pediatric Assessment Triangle (PAT).

The PAT interactiveness, consolability, look/gaze, and speech/

TABLE 1-1 Characteristics of Appearance: The “Tickles” (TICLS) Mnemonic

include observing from a distance; allowing the child to re-

Although an alert, interactive child is usually not

Characteristic Features to Look For TIP

Retractions Supraclavicular, intercostal, or TIP

FIGURE 1-5 The sniffing position opens up the airways to

diminish and the wheezing may not be heard at all.

sniffing position or tripoding. Next, have the caregiver

levels) generates a respiratory alkalosis and helps to

breathing and normal circulation to skin, probably has

pulse oximetry alone. Again, interpret pulse oximetry

TABLE 1-5 Interpretation of Abnormal Breath Sounds

Sound Cause Examples

Stridor Upper airway obstruction Croup, foreign body aspiration,

Wheezing Lower airway obstruction Asthma, foreign body, bronchiolitis

Expiratory grunting Inadequate oxygenation Pulmonary contusion, pneumonia, drowning

Inspiratory crackles Fluid, mucus, or blood in airway Pneumonia, pulmonary contusion

TABLE 1-6 Normal Heart Rate for Age TIP

Pulse Quality. Feel the pulse to ascertain pulse qual-

when performed consecutively on a child who is not

do not delay transport to obtain a blood pressure. Re-

TABLE 1-8 AVPU Scale

Category Stimulus Response Type Reaction

Alert Normal environment Appropriate Normal interactiveness for age

Verbal Simple command or Appropriate or Responds to name; nonspecific or

Painful Pain Appropriate, Withdraws from pain or sound or motion

Unresponsive No perceptible response to any stimulus

Abnormal Appearance and the AVPU Scale. As- Exposure

TABLE 1-9 Pediatric Glasgow Coma Scale

Score Child Infant

4 Opens eyes spontaneously Opens eyes spontaneously

Chapter 15 Medicolegal and Ethical Procedures��335

17 Intraosseous Needle Insertion�� 409 24 Removing and Replacing a