Oklahoma Prehospital Pediatric Supplement Developed by the Oklahoma EMSC Resource Center for the: “Infants and Children Module of the 1994 EMT-Basic Curriculum” PART 1: INTRODUCTORY 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center Introduction OSDH-EMS approved PAC’s course to include in EMT-B 1998’s NSC in 1993 USDOT-NHTSA: EMT-B 1994’s NSC in 1995 EMSC Pediatric Supplement (Revision of PAC’s) to include in EMT-B 1994’s NSC in 1996 Mandatory inclusion into EMT-B courses 2003 Oklahoma EMSC Resource Center

PART 1: Introductory - Injury Prevention Methodology This section covers the following informational areas. - Emergency Medical Services for Children - Injury Prevention Methodology - Anatomy and Physiology - Approaching Children - Vital Signs Assessment - Assessment Tools 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center Objectives Define Emergency Medical Services for Children (EMSC). Objective: 6-1.0 Discuss how an integrated EMSC system can affect patient outcome. Objective: 6-1.0 A Identify methods/mechanisms of injury prevention for Infants and Children. Objective: 6-1.0 B 2003 Oklahoma EMSC Resource Center

Objectives (Continued) Identify two (2) anatomic and physiologic differences between children and adults regarding skin and body surface. Objective: 6-1.2 A Identify four (4) areas to consider when taking the child’s history. Objective: 6-1.3 A 2003 Oklahoma EMSC Resource Center

Objectives (Continued) Describe important factors in taking and interpreting vital signs. Objective: 6-1.3 B Pulse Respirations Blood Pressure Temperature Identify a minimum of four (4) significant differences between the adult and pediatric airway which affect ventilation. Objective: 6-1.3 C 2003 Oklahoma EMSC Resource Center

Emergency Medical Services for Children (EMSC) OBJECTIVE: 6-1.0 Definition A program designed to reduce child and youth mortality and morbidity due to severe illness or trauma. History 1984 Legislation National Management MCHB NHTSA Oklahoma Management OUHSC 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center EMSC (Continued) National Resource Centers National EMSC-NRC National EMSC Resource Alliance (NERA) Oklahoma Resource Center Oklahoma EMSC Resource Center Oklahoma Education and Training Pediatric Specialty Courses PALS PEPP PPC ENPC 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center EMSC (Continued) Prehospital Curricula Pediatric ’94 NSC Supplement Injury Prevention Bystander Care Emergency 1st Care for Childcare Providers Childcare Health and Safety Courses Other Areas Pediatric Resource Library Education Assessment and Management Tools Information Center Instructional Outcome Statistics and Improvement 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center EMSC (Continued) OBJECTIVE 6-1.0 A Integrated EMSC Systems Prevention Prehospital E D’s I C U’s Rehab Community Psychological Trauma Systems State Agencies 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center EMSC (Continued) Patient Outcome Affect Prevention Reduction Emergencies Disability Death Negative Impact Family Community 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center Injury Prevention OBJECTIVE 6-1.0 B Methodology and Mechanisms C P R and 1st Aid Training Certification Requirement Bicycle Safety Community Injury Prevention Programs Data Analysis Common Injury Specific Education 2003 Oklahoma EMSC Resource Center

Anatomy and Physiology (A&P) OBJECTIVE 6-1.2 A Skin and Body Surface Area (BSA) Infants and Young Children Head = 20% BSA BSA Larger in Proportion to Body Mass Changes by Body Part through Childhood Assumes Adult as Adolescent Thin Skin and Less Subcutaneous Fat Prone to Hypothermia and Deeper Burns than Adult Resuscitation and Drug Therapy Reduced in Hyperthermia Newborn Temperature Regulation Not Well Developed 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center A & P (Continued) 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center Pediatric Approach OBJECTIVE 6-1.3 A Obtaining a History Primary Caregiver Information Reassures and Calms Elements Similar to Adult Additional Elements Birth Weight Problems with Pregnancy Current Estimated Weight 2003 Oklahoma EMSC Resource Center

Pediatric Approach (Continued) Cooperation Enhancement Permit “Transition Phase” Level of Child Calm and Friendly Mannerism Cooperation of Child Uncooperative Child A-B-C’s Appropriate? Condition Known? Don’t Waste Time! 2003 Oklahoma EMSC Resource Center

Pediatric Approach (Continued) General Examination Guidelines Remain and Display Calmness Assessment Life-Threatening = Head to Toe Non-Life-Threatening = Toe to Head Non-Traumatic = In Caregivers Lap/Arms Use Assessment Tools Take Opportune Advantages Color and Moistness of Mucous Membranes Presence of Tears Inspiratory Breath Sounds 2003 Oklahoma EMSC Resource Center

Pediatric Assessment Triangle (PAT) APPEARANCE WORK OF BREATHING CIRCULATION TO SKIN PAT does not exclude an initial or focused assessment, but by precluding it complements them giving opportunity for immediate interventions to be established. 2003 Oklahoma EMSC Resource Center

Pediatric Trauma Score (PTS) COMPONENTS +2 +1 -1 WEIGHT >20 kg (>44 lbs) 10-20 kg (22-44 lbs) <10 kg (<22 lbs) AIRWAY PATENT MAINTAINABLE NON – MAINTAINABLE SYSTOLIC BP (AUSCULTATED) >90 mmHg 50-90 mmHg <50 mmHg (PALPATED PULSE) RADIAL CAROTID NONE MENTAL STATUS Awake VERBAL OR PAIN UNRESPONSIVE FRACTURES CLOSED OR SUSPECTED MULTIPLE OPEN OR CLOSED WOUNDS MINOR MAJOR BURNS OR PENETRATING 2003 Oklahoma EMSC Resource Center

Other Assessment Tools GLASGOW COMA SCALE (GCS) EYES MOTOR VERBAL 4 SPONTANEOUS 3 SPEECH 2 PAIN 1 NONE 6 OBEYS COMMANDS 5 LOCALIZED PAIN 4 WITHDRAWS TO PAIN 3 DECORTICATE/FLEXION 2 DECEREBRATE/EXTENSION 1 NONE 5 ORIENTED/BABBLES 4 CONFUSED/CRYING 3 CRY TO PAIN 2 INCOMPREHENSIBLE 1 NONE 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center AGE kg H-R R-R SYS-BP DIAS-BP TIDAL VOLUME N-B 3 120-160 30-60 74-100 50-70 30-45 mL 1 m 4 120-160 30-60 74-100 50-70 40-60 mL 2 m 5 120-160 30-60 74-100 50-70 50-75 mL 3 m 6 120-160 30-60 74-100 50-70 60-90 mL 6 m 7 120-160 30-60 74-100 50-70 70-105 mL 8 m 8 110-150 30-60 74-100 50-70 80-120 mL 10 m 9 110-150 30-60 74-100 50-70 90-135 mL 1 y 10 90-140 20-40 82 54 100-150 mL 1 y 11 90-140 20-40 82 54 110-165 mL 2 y 12 90-140 20-40 84 56 120-180 mL 2 y 13 90-140 20-40 84 56 130-195 mL 3 y 14 90-140 20-40 86 58 140-210 mL 3 y 15 90-140 20-40 86 58 150-225 mL 4 y 16 80-120 20-40 88 60 160-240 mL 4 y 17 80-120 20-40 88 60 170-255 mL 5 y 18 60-120 16-30 90 60 180-270 mL 5 y 19 60-120 16-30 90 60 190-285 mL 6 y 20 60-120 16-30 92 62 200-300 mL 7 y 22 60-120 16-30 94 62 220-330 mL 7 y 24 60-120 16-30 94 62 240-360 mL 8 y 26 60-120 16-30 96 64 260-390 mL 9 y 28 60-120 16-30 98 66 280-420 mL 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center Vital Signs OBJECTIVE 6-1.3 B PULSE CENTRAL Carotid Femoral PERIPHERAL Radial Brachial Popliteal Pedal 2003 Oklahoma EMSC Resource Center

Vital Signs (Continued) Monitor Pulse 30 seconds minimum Rate and Quality Central and Peripheral Tachycardia (Fast) and Triggers Compensatory Mechanism Shock Anxiety Fever Pain Medical Illness Traumatic Injury Environmental Insult 2003 Oklahoma EMSC Resource Center

Vital Signs (Continued) Bradycardia (Slow) and Triggers End Stages Shock Hypothermia Hypoxia/Hypoxemia Cardiac Pathology Congenital Anomalies Certain Medications Rates Decrease through Childhood to Adolescence 2003 Oklahoma EMSC Resource Center

Vital Signs (Continued) RESPIRATION OBSERVATION Begins with P-A-T Prior to and During Exam For Following Tachypnea (Fast) or Bradypnea (Slow) Hyperpnea (Deep) or Hypopnea (Shallow) Apnea (Absent) Use of Accessory Muscles Intercostal, Subcostal, Subclavicular, or Diaphragmatic Noises Wheezing (Inspiratory and/or Expiratory), Grunting (Expiratory), Rhonchi (Upper Airway Rattling), Rales (Lower Airway Crackles) Nasal Flaring 2003 Oklahoma EMSC Resource Center

Vital Signs (Continued) Tachypnea (Fast) and Triggers Compensatory Mechanism Shock Anxiety Fever Pain Medical Illness Traumatic Injury Environmental Insult Monitor 30 seconds minimum Rate, Depth, and Quality 2003 Oklahoma EMSC Resource Center

Vital Signs (Continued) BLOOD PRESSURE Compensatory Mechanism Sustains Normotension (Normal BP) Longer in Pediatrics Hypotension (Low BP) Confirms Decompensated Shock Peripheral Pulse Presence Infants (Birth to 12 months) = Minimum Systolic Pressure of 60 mmHg Children (1 year to 8 years) = Minimum Systolic Pressure of 70 + (2 x Age in Years) Normal Diastolic = 2/3 Systolic Appropriate Size BP Cuff Mandatory 2003 Oklahoma EMSC Resource Center

Vital Signs (Continued) TEMPERATURE Protective Mechanism Environmental (Heat and Cold) Regulator Microbial Protection Assessment Rectally (Most Accurate): Normal = 36º C (96.8 º F) Axillary or Tympanic: Normal = 36.5º C (97.6 º F) Orally: Normal = 37º C (98.6 º F) Fever: Most common cause of seizure in infants 2003 Oklahoma EMSC Resource Center

Vital Signs (Continued) PULSE OXIMETRY Placement Proximal to Central Circulation Earlobe = Recommended Site Administer O2 if SAO2 < 95% CO binds with Hemoglobin 200 times faster than O2 Pulse Ox of NO VALUE in such case 2003 Oklahoma EMSC Resource Center

Airway: Pediatric vs Adult OBJECTIVE 6-1.3 C Airway Differences Pediatric Head Prominent Occiput Tongue Larger More Anterior Epiglottis “U” Shaped Floppier Protrudes more in Laryngopharynx 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center Airway (Continued) Pediatric (Continued) Trachea Shorter Infant: 4-5 cm Child: 8 cm More Flexible Rings Less Well Developed Smallest Airway Diameter = Cricoid Ring Larynx More Anterior More Cephalad Cords Shorter and Concave Lungs: (Tidal Volume Dependent on Diaphragmatic Movement) Adult Opposite that Mentioned 2003 Oklahoma EMSC Resource Center

Oklahoma EMSC Resource Center Summary: Section 1 EMSC: Defined and Integrated Pediatric Injury Prevention Methodology Pediatric A&P vs Adult Approach to Obtaining Medical History Assessing and Interpreting Vital Signs Pediatric vs Adult Airway 2003 Oklahoma EMSC Resource Center