BLS Management of the Peds Patient By Daniel B. Green II, NREMT-P, CCP

Objectives Review developmental milestones of children Use the pediatric assessment triangle to assess pediatric patients Discuss modifications to patient assessment based on age Review common pediatric illnessess and treatments

Pediatric Development

Pediatric Development

Age and Weight Important to be able to estimate ages and weights for pediatric patients Affects treatment decisions, particularly for AED and CPR

Age and Weight

Age and Weight

Developmental Characteristics Children have different behaviors at different ages Tailor your assessment

Newborns and Infants Birth to 1 Year Do not like cold Do not like separation from primary caregivers Let parent or caregiver hold child during assessment Ask caregiver to expose areas for examination Warm stethoscope bell before placing on child

Newborns and Infants Birth to 1 Year Ask caregiver to comfort crying child Try distraction: pen or toy Check fontanels Bulging indicates possible increased intracranial pressure Sunken may indicate dehydration

Toddlers 1–3 Years Sense of independence but unable to communicate complex ideas Do not like strangers or separation from parents Require assurance May consider illness or separation from family as punishment

Toddlers 1–3 Years Place bell of stethoscope under shirt, rather than taking off clothing Consider demonstrating procedure such as chest auscultation on stuffed toy before using on child May not tolerate oxygen mask Use blow-by oxygen

Preschoolers 3–6 Years More developed concrete thinking skills Ask for their version of events and feelings Frightened of potential pain, blood, injury Reassure, provide simple explanations Allow parent or caregiver to remain Protect modesty

School Aged Children 6–12 Years Have basic idea of body and its functions Very literal Aware of and afraid of dying, pain, deformity, permanent injury Use reassurance and include them in discussions of care

Adolescents 12–18 Years More thorough understanding of A&P Able to process and express complex ideas Good risk takers, poor judges of consequence Sense of immortality Speak respectfully Protect privacy

The Pediatric Airway Head Tongue Trachea Proportionally larger and heavier than body Tongue Larger in proportion to lower jaw Falls back, occluding airway Trachea Thinner, more elastic May close off with hyperextension

Breathing Infants breath primarily through nose Nose may be blocked with secretions Infant and child have higher respiratory rate Abdominal breathers Tire quickly when stressed

Pediatric Assessment Triangle

Pediatric Assessment Elements of the pediatric assessment triangle Appearance and environment Work of breathing Circulation

Appearance and Environment Key questions Is scene safe? Is there an obvious mechanism of injury? Is environment safe for a child? Is child active and attentive? Can child make eye contact, respond to parent’s voice?

Work of Breathing Look for symmetrical chest movement Note respiratory rate Primary causes of cardiac arrest in children are respiratory disorders

Abnormal Findings Stridor Retraction of chest wall muscles Harsh, high pitched sound during inhalation or exhalation Indicates partial upper airway obstruction Retraction of chest wall muscles Muscles pulling in between ribs, above sternum with inspiration Nasal flaring Extended opening or flaring of nostrils Wheezing High pitched sounds created by air moving through narrowed air passages in lungs

Assessing Circulation Central perfusion Supply of oxygen to and removal of wastes from central circulation Asses with brachial and femoral pulse checks Check capillary refill Assess skin temperature, color, and moisture

Assessing Circulation BP difficult to obtain below 3 years of age Rely on mental status, quality of pulses, and capillary refill Children 3 Ensure right size BP cuff Be aware of variation of vital signs with age

Compensating/Decompensating Children will compensate for poor respirations and circulation However, decompensation may develop quickly

Respiratory Emergencies in Infants and Children Respiratory distress Respiratory failure Respiratory arrest Airway management Airway adjuncts Oxygen therapy Assisted artificial ventilations Shock

Respiratory Distress Most common cause in pediatric patients is asthma Also includes Chronic lung disease Airway obstruction Congenital heart disease Foreign body aspiration Chest wall trauma

Definitions Respiratory distress Respiratory failure Abnormal physiologic process that prevents adequate gas exchange Respiratory failure Inability of respirations to maintain adequate oxygenation and ventilation Respiratory arrest Absence of breathing

Upper Airway Obstruction Partial obstruction Stridor on inspiration Complete obstruction No crying, no speaking, no coughing Cyanosis

Lower Airway Obstruction Wheezing Prolonged, labored exhalations Rapid respiratory rate No stridor

Signs of Respiratory Distress in Children Altered mental status Flared nostrils Pale or cyanotic lips or mouth Noisy respirations (stridor, grunting, gasping, wheezing) Respiratory rate greater than 60 Retractions Use of abdominal muscles for breathing (see-saw breathing) Poor peripheral perfusion Decreased heart rate

Signs of Respiratory Failure Decreased mental status Poor eye contact No response to verbal stimuli Pale, cyanotic skin Delayed capillary refill, weak pulses Fatigue, floppy, head bobbing

Continuing Respiratory Failure Without immediate intervention, child will continue to deteriorate Respiratory rate 10/min Unresponsive, limp Decreasing heart rate Eventual respiratory and cardiac arrest

Airway Management Airway is primary concern for children Modify head tilt/chin lift to maintain neutral position Avoid hyperextension or flexion Consider placing towel under body to maintain neutral airway position

Suctioning Secretions and Vomit Use bulb-type suction device for suctioning nose and mouth of infant For larger children, use thin flexible plastic catheter Use rigid catheter for removing thick secretions and vomit

Principles of Suctioning Administer oxygen prior to suctioning Suction for maximum of 5 seconds at a time Do not touch the back of the throat May slow heart rate and cause soft-tissue damage

Partial Airway Obstruction Alert Noisy respirations Increased work of breathing Retractions around ribs and sternum Pink mucous membranes Good peripheral pulses

Managing Partial Airway Obstruction Place child in position of comfort Likely sitting up Calm child Allow child to sit with parent or caregiver Provide oxygen by mask or blow-by technique Let child or caregiver hold oxygen device

Management of Airway Obstruction Intervene if following signs are noted Absence of speaking or crying Ineffective cough Altered mental status Respiratory arrest

Children Under 1 Year of Age If ventilation is ineffective or impossible, clear airway 5 back blows 5 chest thrusts If object is visible, remove Continue until effective

Children Over 1 Year of Age If ventilation is ineffective or impossible, clear airway Perform chest compressions Do not perform blind finger sweeps

Shock Causes in children Less common Vomiting Diarrhea Infection Trauma Blood loss Less common Allergic reactions Poisoning

Cardiac Causes of Shock Very rare in children Occasionally may have child with congenital or chronic heart disease

Signs and Symptoms of Shock Rapid heart rate Rapid respiratory rate Cool extremities Pale skin, dry mucous membranes Delayed capillary fill time Weak central pulse Weak or absent distal pulse Decreased response to environment “Floppy” muscle tone

Questions to Ask Caregiver Has child been vomiting or had diarrhea? How many wet diapers in the past 24 hours?

Management of Shock in Children Child showing signs of shock is very sick Children tend to compensate well, then decompensate quickly

Emergency Care for Shock BSI and scene safety Ensure adequate ABCs Control obvious bleeding Administer high flow oxygen Keep patient warm Elevate legs, if possible Expedite transport/call for ALS backup

Trauma in Children Leading cause of death in infants and children Head injuries Chest injuries Abdominal injuries Injuries to the extremities Burn injuries

Common Mechanisms of Injury Motor vehicle crash Motor vehicle versus bicycle Pedestrian versus motor vehicle Fall from height Diving into shallow water Others Burns, sports injuries, child abuse

Motor Vehicle Crashes Most common cause of blunt trauma Unrestrained child Injuries to head and neck Restrained child Abdominal and lower spine injuries

Motor Vehicle versus Bicycle Injuries to Head Spine Abdominal injuries

Pedestrian versus Motor Vehicle Bumper hits abdomen or upper legs Child thrown and lands on head With toddlers, bump will impact head and neck Often associated with abdominal, head, upper leg, pelvic injuries

Head Injuries Use modified jaw-thrust Tongue obstruction in supine patient most common cause of hypoxia Developing respiratory failure and arrest Watch for Nausea, vomiting Secondary injuries

Chest Injuries Children's ribs are more pliable Will bend further before breaking May be significant internal bleeding without obvious external signs of injury

Abdominal Injuries More common in children than adults Abdominal muscles are weaker than in adults Internal organs are less securely anchored Suspect abdominal injury in child who is deteriorating without outward signs of injury Be aware of gastric distension when providing assisted ventilations

Injuries to the Extremities Isolated limb injuries more frequent in pediatric population Rarely life-threatening Use of PASG prohibited in children Ensure you know local protocols

Burn Injuries Impaired skin integrity and exposure increase risk of hypothermia Know Rule of 9s for infants and children Heads are larger relative to body Cover with sterile nonstick gauze Transport to burn center

Emergency Medical Care BSI, scene survey Maintain cervical stabilization Use modified jaw-thrust Suction if necessary Provide oxygen Assist respirations as required Secure to backboard Transport to appropriate facility

Seizures Causes Infection Poisoning Hypoglycemia Hypoxia Head trauma

Febrile Seizures Most common cause of seizures in infants and children Usually associated with viral illness

Assessment of Seizure Patient Ask caregiver How many seizures child has had How long seizures lasted What part of the body was convulsing Recent history of fever or chronic seizure disorder What medications child takes

Emergency Care for Seizures Protect cervical spine as necessary Ensure patent airway Provide oxygen Suction, assist respirations, if required Transport to appropriate facility

Poisoning Common cause is accidental ingestion Look for substance and container at scene

Emergency Care for Poisoning If responsive Contact medical direction Administer oxygen and transport If unresponsive Maintain patent airway Suction and assist ventilations as necessary

Fever Seldom life-threatening on its own Causes usually infectious e.g., meningitis Transport and be alert for seizures

The Last Word Keys are airway, breathing, and oxygenation Cardiac events in children are almost always preceded by an obstructed airway or inadequate respirations EMS providers often intimidated by pediatric calls Practice your skills when working with children Remain calm and supportive