Children Are Not Just Small Adults

Body surface area large for weight, making infants susceptible to hypothermia.

All brain cells present at birth; myelinization and further development of nerve fibers occur during first year.

Anterior fontanelle and open sutures palpable up to about 18 months. Posterior fontanelle closes between 2 and 3 months. Tongue large relative to small nasal and oral airway passages.

Head proportionately larger, making child susceptible to head injury. Higher metabolic rate, higher oxygen needs, higher caloric needs. Until puberty, percentage of cartilage in ribs is higher, making them more flexible and compliant. Until about 10 years, there is a faster respiratory rate, fewer and smaller alveoli, and less lung volume. Tidal volume is proportional to weight (7 to 10 mL/kg). Up to about 4 or 5 years, diaphragm is primary breathing muscle. CO2 is not effectively expired when child is distressed, making child susceptible to metabolic acidosis. Until puberty, bones are soft and more easily bent and fractured.

Short, narrow trachea in children under 5 years makes them susceptible to foreign body obstruction.
Until late school age and adolescence, cardiac output is rate dependent not stroke volume dependent, making heart rate more rapid. Abdomen offers poor protection for the liver and spleen, making them susceptible to trauma. Until 12 to 18 months of age, kidneys do not concentrate urine effectively and do not exert optimal control over electrolyte secretion and absorption.

Muscles lack tone, power, and coordination during infancy. Muscles are 25% of weight in infants versus 40% in adults.
Until later school age, proportion of body weight in water is larger, with more water in extracellular spaces. Daily water exchange rate is much higher. Blood volume is weight dependent: 80 mL/kg.

Children are not just small adults.There are important anatomic and physiologic differences between children and adults that will change based on a childs growth and development.

Common Alterations in Chest Configuration

Normal Infant (Round Shaped)

Funnel Chest

Two types of abnormal chest shape. A, Funnel chest

(pectus excavatum). B, Pigeon chest (pectus carinatum).

FIGURE 3521

Atlas Axis Clavicle T1 Angle of Louis Rib 2 Scapula Sternum Intercostal space 5 Xiphoid process T12 Clavicle

Intercostal spaces and ribs are numbered to describe the location of findings. A,To determine the rib number on the anterior chest, palpate down from the top of the sternum until a horizontal ridge, the angle of Louis, is felt. Directly to the right and left of that ridge is the second rib.The second intercostal space is immediately below the second rib. Ribs 312 and the corresponding intercostal spaces can be counted as the fingers move toward the ab-domen.B,To determine the rib number on the posterior chest, find the protruding spinal process of the seventh cervical vertebra at the shoulder level.

FIGURE 3522

Right midclavicular line

Vertebral line

Sternal line
Right scapular line

Right upper lobe Right middle lobe Right lower lobe

Left upper lobe Left lower lobe

Right posterior axillary line

Right anterior axillary line

A B

The sternum and spine are the vertical landmarks used to describe the anatomic location of findings. The distance between the finding and the center of the sternum (midsternal line) or the spinal line can be measured with a ruler. Imaginary vertical lines, parallel to the midsternal and spinal lines, are used to further describe the location of findings. A, anterior vertical landmarks,B, posterior vertical landmarks.

Anatomic Landmarks of the Thorax

Inspection
Movement of the chest wall Rate and Depth of Respiration

The sense of touch to make judgment about pulsation, vibration and to locate structures or masses

Palpation of the chest

Tactile fermitus

Respiratory excursion

Light palpation

Applying fingertip pressure to depress the

skin surface approximately half inches and then moving fingertips in circular motion

Sound generated by the larynx travels distally along the bronchial tree to set the chest wall in resonant motion. The capacity to fell sound on the chest wall is called vocal or tactile fremitus.

Estimation of thoracic expansion and it may reveal significant information about the

symmetry of breathing difference in expansion

Purpose To determine whether underlying tissues are filled with air, fluid or solid material To estimate the size and location of certain structure within the thorax (diaphragm, heart, liver).

Anterior Chest

Posterior Chest

FIGURE 3526 Normal resonance patterns expected over the chest. Tympany is a loud, highpitched sound,like a drum.It is usually heard over an airfilled stomach. Flatness is a soft, dull sound, like the sound made when per-cussing your thigh. It is heard over dense muscle and bone. Dullness is a moderately loud, thudlike sound. It is heard when per-cussing over the liver and heart, and at the base of the lungs (at the level of the diaphragm).Resonance is a loud,lowpitched, hollow sound, like the sound made when percussing a table.It is heard over the lungs. Hyperresonance is a loud, very lowpitched, booming sound. It is usually heard over superinflated lungs. However, because of the thin chest wall in young children, hyperreso-nance may be a normal finding.

Resonance

Cardiac dullness Gastric tympany

Hepatic dullness

Hepatic flatness

Resonance

Dullness

Tympany Flatness

Auscultation

To determine the condition of the lungs by assessing the flow air through the bronchial tree and evaluating the presence of fluid or solid obstruction in the lung structure.

Auscultation
Breathing Sound

Bronchial breath sounds

Bronchovesicular breath sounds

Vesicular breath sounds

Heard

only

over

trachea

near

suprasternal notch. Inspiratory phase is short, and

expiratory phase is long.

Heard on the second intercostal spaces where trachea and bronchi

bifurcate. Inspiration is equal the expiration.

Heard over entire surface of lungs, with exception of upper intra-scapular area and area beneath manubrium.

Inspiration is louder, longer and higher pitched than expiration.

Sound is soft, swishing noise.

The presence of an abnormal condition that affects the bronchial tree and alveoli may produce additional or adventitious sounds.
Crackles: Which result from the passage of air through fluid or moisture.

Wheezes: Which result from the passage of air through narrowed passage ways.
Pleural friction rib: When inflammed pleural surface come together during inspiration

The sound heard through the stethoscope as the patient vocalizes is known as vocal resonance. The vibration produced in the larynx is transmitted to the chest wall as they pass through the bronchi and alveolar tissue.

Vocal resonance: The sound heard through the stethoscope as the patient vocalizes

Bronchophony:
If the patient repeat letter (e), the consolidation transfers the sound into a clearly heard a rather than e

Heart Assessment

Examination of the heart involves the skills of inspection, palpation and auscultation

The point of maximum impulse: (PMI)

It located :
1. lateral to the left mid-clavicles line in 4th intercostals space in children < 7 years

or
2. In 5th intercostals space in children > 7 years.

It is testing for peripheral circulation, the skin is pressed lightly on a central site such as forehead or top of the hand.
The time it takes for the blanched area to return to its original color is the capillary refill time.( about 1-2 seconds)

FIGURE 353

Capillary refill technique: A,Pinch the end of a finger until the skin is blanched. B, Quickly release the finger and watch the blood return to the veins. Count the sec-onds it takes for the color to return or veins to fill. Slow color return or vein filling time could be related to shock or con-striction due to a tight bandage or cast. Small-vein filling time technique: C,Using the index finger, milk a vein on the dorsum of the hand or foot from proximal to distal. D,Release your pressure and color should return promptly.

AB

The heart sounds are produced by the opening and closing of the valves and the
vibration of blood against the wall of the heart and vessels.

The heart sounds are evaluated for: Quality, Intensity, Rate, Rhythm

Normally, two sounds S1 and S2 are heard, which

correspond respectively to the familiar lub dub often used to describe the sounds.

is caused by the closure of the tricusped and mitral valves (sometimes called the atrioventricular valves).

S1

S2
is the result of the closure of the pulmonic and aortic valves (sometimes called semilunar valves).

FIGURE 3527

Sound travels in the direction of blood flow. Rather than listen for heart sounds over each heart valve, auscultate heart sounds at specific areas on the chest wall away from the valve itself.These areas are named for the valve producing the sound. Aortic: Second right intercostal space near the sternum. Pulmonic: Second left intercostal space near the sternum.Tricuspid: Fifth right or left intercostal space near the sternum. Mitral (apical): In infantsthird or fourth in-tercostal space, just left of the left midclav-icular line. In childrenfifth intercostal space at the left midclavicular line.

Second left interspace

Pulmonic valve Third left interspace Second right interspace Aortic valve Fourth left interspace Fifth left interspace (apex)

Mitral valve

Tricuspid valve

Anatomic valve sites and areas of heart sounds for auscultation

1. Aortic area:
Second intercostals space to the right of the sternum.

2. Pulmonary area:
Second intercostals space to the left of the sternum.

3. Left ventricular area: (mitral area)

Forth and fifth intercostals spaces to the left of the sternum.

4. Right ventricular or tricusped area:

Fifth intercostals spaces to the left and right of sternum.

The child is positioned in supine position during examination with pillow under the head and the knee flexed to enhance abdominal relaxation.

To assess the Contour, Symmetry, Characteristics of the umbilicus, skin, pulsations and movement.

Auscultation the abdomen

Peristalsis or bowel sounds.

Abdominal Quadrants and Structure

Palpation of the abdomen

Types of palpation
Superficial palpation

Deep palpation

Guidelines for promoting relaxation during palpation

Have child hold the parents hands and squeeze it if palpation is uncomfortable.

Use the non-palpating hand to comfort the child. Such as placing the free hand on the childs shoulder while palpating the abdomen.
To minimize sensation of tickling during palpation: Have child help with palpation by placing their hand over the palpating hand.

Percussion of the abdomen

Percuss all four quadrants of the abdomen to determine the nature of the underlying tissue.

Hollow organs will produce tympanic sounds and solid or fluid filled tissue will produce a dull sound. e.g. stomach

In males assess for location of the scrotum, size of the penis, glans and urethral meatus. While palpating scrotum for descended testes block inguinal canal with opposite hands. The female genitalia are examined for size and location of the structures of the valva, clitoris, labia mojora, labia minora, uretheral meatus and vaginal orifice.

Joint motions are defined as flexion, extension, abduction, adduction, internal rotation, external rotation and
circumduction. General inspection begins with visual scanning of the body using to a toe) cephalocaudal organization. (head

Spine
The general curvature of the spine is noted

Normal spine

Kyphosis

Lordosis

Normal spine in balance

Mild Scoliosis

Severe Scoliosis

Extremities

Edema

Joints are evaluated for range of motion, swelling heat, tenderness, and

Assess strength of each muscle group. Strength is estimated by having the child use an extremity to push or pull against resistance.

Assess Mental Status.

Assess Sensory Intactness. Assess Sensory Discrimination.

Assess Reflexes.