1. Pediatric Emergencies
Chapter 30
Pediatric Emergencies

2. 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

3. 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

4. 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

5. 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.

6. 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.

7. 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.

8. 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.

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

10. 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.
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11. Airway
The respiratory anatomy of children compared to that of adults.
continued

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

13. 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.

14. 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.

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

16. 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.

17. 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.

18. 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.

19. 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.

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

21. 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.

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

23. 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.

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

25. 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.

26. Adolescent

27. 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.

28. 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.

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

30. 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.

31. 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.

32. 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.

33. 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.

34. Poisoning

35. 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.

36. 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

37. 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.

38. 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.

39. 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.

40. 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.

41. 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

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

43. Shock

44. 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.

45. 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.

46. 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

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

48. Assessment
The pediatric assessment triangle.
continued

49. 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

50. 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

51. 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.

52. 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.

53. 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.

54. 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.

55. 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.

56. 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

57. 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.

58. 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.

59. 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.

60. 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

61. 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

62. 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

63. 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.