Pediatric Emergencies Chapter 30 Pediatric Emergencies

Chapter Objectives 30.1 List and describe the anatomical and physiological differences between children and adults. 30.2 List and describe the six stages of child growth and development. 30.3 List the normal range of vital signs for each pediatric age group. continued

Chapter Objectives 30.4 Understand and be able to incorporate communication tips and techniques for assessing and interacting with a pediatric patient. 30.5 Describe the signs and symptoms of respiratory distress and failure in a child. 30.6 List and describe the signs and symptoms of various pediatric disorders. continued

Chapter Objectives 30.7 List the most common cause of cardiac arrest in pediatric patients. 30.8 List common causes of seizures in pediatric patients. 30.9 List five indicators of potential child abuse and neglect. 30.10 Define sudden infant death syndrome. continued

Chapter Objectives 30.11 Describe and demonstrate how to assess a pediatric patient, using the pediatric assessment triangle. 30.12 Describe and demonstrate how to manage common pediatric illnesses and injuries.

Topics Anatomy and Physiology Human growth and development Common pediatric illnesses and injuries Child abuse and neglect Shock Assessment Management Discussion Points: There is a huge amount of information in this chapter. The number of slides is large, and each provides the opportunity for discussion of the details found in the text.

Case Presentation An eight-year old kayaker has slipped and fallen on a rock with her arm outstretched. She is cradling it against her life jacket, shivering violently, and her lips have turned blue. When you approach she screams and begins to cry. Her grandmother is also at the scene. Discussion Points: The scenario begins to allow you to discern differences between child and adult patients.

Anatomy and Physiology Inherent differences in intellect, size, proportion, and metabolism Large variations in behavior, vital signs, ability to cope occur at various stages of development Discussion Points: The book gives many more details than can be put on a slide – if you have students who are parents they will likely be aware of many of the variations children demonstrate at their various stages of development. Review the stages with your students.

Anatomy and Physiology Compared to adults, a child's head is larger in proportion to the body.

Airway Relatively small mouths and airways Glottis opening is narrow Tongue is proportionally larger & bulbous until about age 8 Tonsils & adenoids swelling can cause respiratory distress Glottis opening is narrow Foreign body obstruction concerns Discussion Points: Review the A&P differences of the airway. continued

Airway The respiratory anatomy of children compared to that of adults. continued

Airway Trachea is shorter, smaller, softer, more flexible May collapse if neck is hyperextended Discussion Points: Review the A&P differences of the airway.

Head Proportionally larger & heavier Brain is proportionally smaller Issues with neutral c-spine/airway mgt Brain is proportionally smaller Discussion Points: Review additional details about the size of the head, and especially the small brain with the concerns that may result from a head injury.

Skin, Bones, Joints Surface area is greater, skin is thinner Less muscle mass & body fat Musculoskeletal system is immature and grows rapidly Bones, joints, ligaments are softer & more flexible Higher rate of internal organ injury Greenstick fractures Growth plate issues Discussion Points: Details in the text include the benefits to the child of their less developed body, but also the concerns related to the types of injury which might be seen.

Metabolism High metabolism rate leads to bursts of energy followed by fatigue Need for regular meals

Breathing Newborns breath through their nose Infants/small children use diaphragm Rates & minute volume are higher High incidence of respiratory failure May be first indication of emergency Discussion Points: Again, the concern for respiratory distress is detailed in the text, and it is noted that this is a major area of difference between children and adults.

Bleeding and Shock Cardiovascular/nervous systems are vulnerable to toxins Proportionally less blood, bleed like adults Initial compensation to shock is better, but fails quickly Hypovolemia is dangerous Thermal regulation can be of concern Discussion Points: With less blood volume, loss of relatively small amounts of bleeding can create shock issues for children very suddently. Be sure to emphasize that children can go into shock with few, if any, signs or symptoms, and that it can happen quickly.

Human Growth and Development Six stages Newborn Infant Toddler Pre-school School-age Adolescent Discussion Points: The stages are described in the next several slides.

Newborn and Infant Newborn spans 28 days Breathing must begin properly Warmth is essential Crying is response to stimuli Infant spans first year of life Dependent on caregivers Vary responses Gross motor skills develop Discussion Points: Though it is unlikely we will see children at these ages on the slopes, they may be in other locations at the area as well as on hiking trails or other outdoor sports environments.

Newborn and Infant • A newborn: birth to 28 days. • An infant: 2–12 months.

Toddler & Pre-School Toddler from 1 to 3 years of age Curiosity may lead to serious injury Speech, fine motor skills develop Limited socialization Pre-school from 3-6 years of age Communication skills improve Motor skills/balance develop Social skills, abstract thinking develop Gender awareness emerges Discussion Points: We are likely to start seeing kids in the pre-school group on the slopes. If your area has special programs for them, you may want to discuss what those are, and how OEC Technicianss might interface with that group.

Toddler & Pre-School • A toddler: 12–36 months. • A preschool child: 3–5 years.

School-Age Care for most basic needs with help Can differentiate emotional/physical pain Controlling emotion is difficult Require simple language Can make decisions, be part of a team Concepts of right, wrong, acceptance, consequences develop Discussion Points: If your area has programs for school-aged children you may interact with them without their parents being in the picture. Whether it is through scouting, school, or church programs it is good for you to review protocols for contacting the parents of injured children. OEC techs need to be aware of the role of leaders, teachers, or chaperones in those protocols, as well as the role of other non-parent adults who might be accompanying children. Additionally, knowing what to do when parents cannot be contacted is also an important issue.

School-Age School-age children: 6–12 years.

Adolescent Ages 12 – 18 Become independent, peer oriented May feel invincible – accidents and injuries common Privacy, sexuality are issues Understand complex thought, develop opinions, influenced by peers Discussion Points: Issues mentioned on the previous slide are relevant here as well. However, this age group may be more outspoken.

Adolescent

Common Illnesses and Injuries Some unique to this population Vary in severity Occur more frequently in one group than others Often respiratory related Discussion Points: The text contains some details here. You will have to determine the depth to which your class will explore them.

Airway Problems Upper Lower Croup Tonsillitis Foreign body airway obstruction Epiglottitis Lower Pneumonia Bronchiolitis Asthma Discussion Points: This slide represents many problems which we may not see at our areas, but knowledge is important to understanding the total child.

Airway Problems In asthma, inflammation of the airways reduces their diameter, causing respiratory difficulty.

Respiratory Failure/Cardiac Arrest Young children are susceptible Heart and respiratory rate increase Respiratory system becomes exhausted – fails Hypoxia follows, then cardiac arrest Bradycardia with resp distress is an ominous sign Discussion Points: The importance of this is noted in the text – that cardiac arrest in children is most often associated with respiratory failure.

Abdominal Pain Common cause is constipation/stool holding Gastroenteritis, appendicitis are also sources Nausea, vomiting, diarrhea also common (NVD) Severe cases lead to dehydration, hypovolemia and shock Discussion Points: These maladies may not be seen at the ski area, but again, understanding the whole child is important.

Seizures Febrile are most common Status epilepticus Absence 6 mos. To 5 years Combination of infection, high temp Most are generalized, short, harmless Status epilepticus Lasts longer than 10 mins. Prolonged post-ictal state 3 or more in a row, no return to normal True emergency Absence Discussion Points: Seizures may be seen more often in children than adults, so understanding the types and characteristics is vital. Additional details are found in the text.

Meningitis and Poisoning Meningitis is caused by an infection Develops over 1-4 days, contagious Lethargy, fever, headache, stiff neck True medical emergency Accidental poisoning Often can’t tell the difference Put things in their mouth Small amounts have large effect Adolescent issues Discussion Points: We are still in topics that OEC techs may not see at their area, but they will be ready for real life applications.

Poisoning

Sudden Infant Death Syndrome Cause is unknown may run in families, be preceded by sleep apnea or anoxia Decline in cases over last 15 years Sleep in nonprone position Avoid soft bedding and objects Not sleeping with adults No known prevention Discussion Points: While unlikely to be encountered, it is worthy of knowledge and awareness.

Trauma Inherent risk taking behavior Leading cause of death Vehicle crashes, firearms, drowning Blunt trauma is leading source of injury Head injury common, severe Lower spine injury incidence Discussion Points: Much of the information on the previous slides referred largely to younger children. Trauma is more prevalent with school-aged children, and especially adolescents in our environment. The text gives information on trauma in younger children as well. continued

Trauma Chest/abdomen injuries transfer energy to organs Contusions and internal bleeding may result Commitio cordis is life threat Blow to the chest, interrupts normal electrical pattern of heart Treated with defibrillation Extremities Greenstick fractures may occur Discussion Points: The 3 problems on this page may represent different age groups for patients, but any of these may be found on the slopes. The issue of internal bleeding, the ability of the younger child to compensate, and shock can be reviewed here.

Burns and Electrocution Scald related are most common in toddler & pre-school Open flame burns common in school- age children and adolescents Chemical burns are less common Electrical injuries occur when infants, toddlers stick objects into outlets or chew cords Discussion Points: The first and last points are self explanatory. A discussion of the source of flame or chemical burns, and the circumstances in which children may be burned would be beneficial.

Child Abuse and Neglect Legal, not medical terms Are crimes Reporting requirements vary by state Transcends culture, class, race, religion Abusers are parents or close adults Shaken baby syndrome Discussion Points: Additional information on recognizing abuse is found in a later slide. Here the issue is understanding a bit about the topics of abuse and neglect. In some states, not reporting suspected abuse is a crime, so this is a serious matter. You should inform students of the reporting requirements in your area.

Child Abuse and Neglect • Physical abuse in a child: multiple fatal injuries. • Physical abuse in a child: cuts from restraints. • Physical abuse in a child: burns from a stove.

Shock Hypovolemic is most common Dehydration due to vomiting, diarrhea, external blood loss or internal bleeding Vascular reserve is smaller, smaller loss is more serious Discussion Points: It has been mentioned and will be found in later slides as well that recognizing shock in children can be a challenge because they compensate well initially, but they can crash rapidly. This is a message that is vital for students to take away from this class. continued

Shock Sepsis, anaphylaxis, poisoning are also causes Cardiogenic is rare Obstructive may occur due to blunt trauma

Shock

Case Update Smiling, you crouch down beside her. You introduce yourself to her and to her grandmother and reassure both of them that you are there to help. You ask and receive the grandmother’s permission to examine the child. Sensing her fear and pain, you ask the child her name. Discussion Points: How do you approach a child? How do you integrate the adult in the child’s care? What non-trauma issues were addressed? What behaviors tend to create a cooperative child patient? This child is at an age we may see at our areas. The concerns for her overall well being as well as care for her specific injury should be emphasized. The value of the cooperation of the grandparent should be pointed out. You may have stories to tell of incidents where you didn’t get such cooperation, and the issues it created. This child is also a “good” patient – again you may have stories of less cooperative children.

Case Update You ask the girl, “Where does it hurt?” She stops crying and points with her left index finger at her right upper arm and shoulder. You carefully lift the child out of the water and onto more stable ground, being careful to protect her injured arm and shoulder. With the help of other OEC Technicians, you remove the child’s life-jacket, compliment her for wearing a helmet, and continue to wrap her torso in the space blanket.

Assessment Pulse/resp rates may change rapidly Crying complicates Stable appearance doesn’t mean no problem All actions take into account developmental stage Discussion Points: The assessment slides, which actually include the next 6 slides as well, focus on the special considerations which must be made for children. As you discuss this you will see that the OEC Technician must take into account the age of the child, his/her behaviors, and whether or not the caregiver is present. Notable differences are that, in younger children, once the area of pain is noted that area will be palpated last, rather than first as with an adult, and that the child may need to be distracted or invited to participate in the assessment. continued

Assessment Pediatric Assessment Triangle Appearance Work of breathing Circulation to skin continued

Assessment The pediatric assessment triangle. continued

Assessment Parental permission, or implied consent Parent cooperation may = child’s Use clues based on child’s behavior Activity level Eye contact Irritable or agitated? Response to caregiver’s voice Discussion Points: If a parent/legal guardian is present, no matter the age of the child, it is the parent that must give permission for treatment. If any other adult is with the child, implied consent kicks in. You should inform your students of your area’s protocol for attempting to locate/contact parents prior to making treatment/transport decisions. This would be especially important if the parent/guardian is not at the area and you have a serious situation where the “Golden Hour” is passing as you deal with those contact attempts. You may also want to discuss strategies for handling various parent scenarios – the overly concerned, the resister, etc. There is additional information in the text on the child behavior clues to use in your discussion. continued

Assessment Respiratory effort Appearance is striking May be in tripod position “Sniffing” position in infants Drooling (epiglottitis) Use of accessory muscles See-saw (paradoxical) breathing Listen for sounds of breathing Check rate Is air moving well? Discussion Points: As respiratory clues have been a theme throughout this chapter, you will want to be sure that students understand what the various aspects of respiratory effort signal in a child’s assessment. continued

Assessment Circulation History Check skin color characteristics May come from caregiver Talk to child if possible, be calm Adjust vocab as appropriate Be aware of privacy issues Discussion Points: History may come from a caregiver or the child. Tell students that with adolescents, history taking should also include interviewing their friends who may have seen the injury occur.

Honesty, Trust, Communication Be honest – trust lost may not be regained, can affect care Interaction with caregiver could “make or break” scene Find out what is normal Ask about NVD Cover history Discussion Points: The communication with the caregiver is emphasized as that is the person that knows the child the best – more details are in the text on this. You will want to cover protocols for recording the caregiver’s information in your incident documentation if they are different from direct patient information.

Honesty, Trust, Communication Explain actions Screaming/crying can create difficulty Use eye contact, empathy – don’t show irritation/anger Don’t promise what you can’t deliver Phrase questions carefully Give child choices if possible Discussion Points: Info on this slide is also going to be age related. The question phrasing is valid for most ages, as you don’t want to give any youngster the opportunity to say “no” to necessary treatment.

Physical Exam May want to distract young children and involve them in the process Allow them to remain in parent’s arms Take pulse, respirations (most important vital sign for young child) Use pediatric cuff for BP Do regular secondary Do head after trunk/extremities Palpate injured area last Discussion Points: The book makes several suggested modifications in the physical exam, with many of them related to the age of the child. Two of those are noted in the sub-points of the last bullet. You may want to discuss others that students who are also parents might suggest.

Child Abuse Suspect child abuse if: The parent is verbally abusive to child The child withdraws completely or shows true fear Injuries are found to multiple body parts/various ‘ages’ History is inconsistent with injury pattern Be aware of your state’s reporting requirements Discussion Points: This is a touchy topic for most individuals who may have heard horror stories of both abuse and of parents who have been falsely accused and investigated. You will need to know what level of responsibility OEC Technicians have for reporting suspected abuse based on your state laws.

Management Control external bleeding aggressively If sick child isn’t getting better with care, they are likely getting worse Be aware of neutral head position Use high flow oxygen/ped’s mask Airway related disorders should be transported quickly Discussion Points: The text mostly notes that treating a child uses the same techniques as treating an adult for similar injuries using equipment that matches the size of the patient. You should be sure that students know where to find the ped’s equipment in your first aid area. Much of what is on this slide and the next relates to special concerns for the child, especially in more illness related situations, again with an emphasis on respiration. continued

Management Monitor seizure patient, when it stops open/clear airway Use recovery position if no spinal injury is suspected Febrile seizures are managed by cooling Shock can be present with no S or S If suspected, transport Discussion Points: The text notes that seizures in a child are managed in a similar manner as adults, with the exception of the febrile seizure. You may want to remind students of previous information of febrile seizures. Shock, and its potential without S&S has also been mentioned a number of times before in the chapter, so this is one last opportunity to remind students of its impact on caring for children.

Case Disposition After confirming that there are no immediate threats to life, your secondary assessment reveals an obvious deformity over the lateral third of the right clavicle with bruising and swelling noted over the girl’s right upper arm. You tell her that you’d like to splint her arm, which will help take away some of the pain. Discussion Points: What injuries are discovered? What concerns does the patient have? What is the role of the grandmother? What treatment/transport decisions were made? This child and caregiver were calm and cooperative, and this gives you one more opportunity to point out what the OEC Technician did to help that situation along with the regular discussions of assessment, care, and transport. Since your students will encounter less calm and cooperative patients, you may want to discuss strategies to try in these instances.

Case Disposition You explain, however, to both the girl and her grandmother, that it might hurt when you move the arm into the splint and sling. The girl looks at her grandmother, who gives her an encouraging smile and tells you, “We’ll both be big girls.” After splinting, you accompany the child and her grandmother downriver in a large oar boat. Her vital signs remain stable. An ambulance takes her to the hospital. She has a broken clavicle.

Chapter Summary Children are not miniature adults; they do not see, perceive, or respond to the world as adults do. Children undergo six growth and development stages: the newborn stage, infancy, the toddler stage, the preschool period, the school-age period, and adolescence. Discussion Points: What are some of the unique concerns associated with pediatric patients? Anatomy? Physiology? Behavior? How do assessment procedures differ? How is shock different with children? How does treating children differ from treating adults? Use this opportunity to involve students in wrapping up this topic with a review of the major points. continued

Chapter Summary Whenever possible, incorporate caregivers or parents into the assessment process. Be sensitive to an adolescent’s need for independence, respect, and privacy. A child can maintain a normal blood pressure and appearance during compensated shock. Children can change rapidly continued

Chapter Summary Assume that the condition of a child who looks sick and is not improving with care is worsening. Report suspected child abuse to the proper authorities. Approach children slowly and gently. Smile and be friendly. A child who is crying or screaming has a patent airway. continued

Chapter Summary A slow heart rate in a child with respiratory distress is an ominous sign of severe illness and impending cardiac arrest. Cardiac arrest in children is usually preceded by respiratory failure. Parents often demonstrate their fear by showing anger or irritation.