Pediatric Emergencies

Pediatric Emergencies
Chapter 34 Pediatric Emergencies Chapter 34: Pediatric Emergencies

National EMS Education Standard Competencies (1 of 10)
Special Patient Populations Applies a fundamental knowledge of the growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs. National EMS Education Standard Competencies Special Patient Populations Applies a fundamental knowledge of the growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs.

Patients With Special Challenges Recognizing and reporting abuse and neglect Health care implications of Abuse Neglect Homelessness Poverty Bariatrics National EMS Education Standard Competencies Patients With Special Challenges • Recognizing and reporting abuse and neglect Health care implications of • Abuse • Neglect • Homelessness • Poverty • Bariatrics

Health care implications of (cont’d) Technology dependence Hospice/terminally ill Tracheostomy care/dysfunction Home care Sensory deficit/loss Developmental disability National EMS Education Standard Competencies • Technology dependence • Hospice/terminally ill • Tracheostomy care/dysfunction • Home care • Sensory deficit/loss • Developmental disability

Pediatrics Age-related assessment findings, and age-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies Upper airway obstruction Lower airway reactive disease Respiratory distress/failure/arrest National EMS Education Standard Competencies Pediatrics Age-related assessment findings, and age-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies • Upper airway obstruction • Lower airway reactive disease • Respiratory distress/failure/arrest

Age-related assessment findings, and age-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies (cont’d) Shock Seizures Sudden infant death syndrome National EMS Education Standard Competencies • Shock • Seizures • Sudden infant death syndrome

Age-related assessment findings, and developmental stage-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies Upper airway obstruction Lower airway reactive disease Respiratory distress/failure/arrest Shock National EMS Education Standard Competencies Age-related assessment findings, and developmental stage-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies • Upper airway obstruction • Lower airway reactive disease • Respiratory distress/failure/arrest • Shock

Age-related assessment findings, and developmental stage-related assessment and treatment modifications for pediatric-specific major diseases and/or emergencies (cont’d) Seizures Sudden infant death syndrome Gastrointestinal disease National EMS Education Standard Competencies • Seizures • Sudden infant death syndrome • Gastrointestinal disease

Trauma Applies fundamental knowledge to provide basic emergency care and transportation on assessment findings for an acutely injured patient. National EMS Education Standard Competencies Trauma Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Special Considerations in Trauma Recognition and management of trauma in Pregnant patient Pediatric patient Geriatric patient National EMS Education Standard Competencies Special Considerations in Trauma Recognition and management of trauma in • Pregnant patient • Pediatric patient • Geriatric patient

Pathophysiology, assessment, and management of trauma in the Pregnant patient Pediatric patient Geriatric patient Cognitively impaired patient National EMS Education Standard Competencies Pathophysiology, assessment, and management of trauma in the • Pregnant patient • Pediatric patient • Geriatric patient • Cognitively impaired patient

Introduction (1 of 2) Children differ anatomically, physically, and emotionally from adults. Illnesses and injuries that children sustain, and their responses to them, vary based on age or developmental level. Important to remember that children are not small adults Fear of EMS providers and pain can make the child difficult to assess. Lecture Outline Introduction A. Children differ anatomically, physically, and emotionally from adults. 1. The illnesses and injuries that children sustain, and their responses to them, vary based on age or developmental level. 2. It is important to remember that children are not small adults. a. Depending on his or her age, the child may not be able to tell you what is wrong. 3. Fear of EMS providers and pain can make the child difficult to assess. a. Parents or primary caregivers may be stressed, frightened, or behaving irrationally. b. For these reasons, pediatrics, the specialized medical practice devoted to the care of young patients, can be challenging.

Introduction (2 of 2) Once you learn how to approach children of different ages and what to expect while caring for them, you will find that treating children also offers some very special rewards. Lecture Outline B. Once you learn how to approach children of different ages and what to expect while caring for them, you will find that treating children also offers some very special rewards. 1. Their innocence and openness can be appealing. 2. Children often respond to treatment much more rapidly than adults do.

Communication With the Patient and the Family
When caring for a pediatric patient, you must care for parents or caregivers as well. Caregivers often need emotional support. A calm parent usually results in a calm child. An agitated parent means child will act same way. Remain calm, efficient, professional, and sensitive. Lecture Outline II. Communication With the Patient and the Family A. Caring for an infant or child means that you must care for the parents or caregivers as well. 1. Family members or caregivers often need emotional support. B. A calm parent usually results in a calm child. 1. The parent can often assist you with the child’s care. 2. An agitated parent means the child will act the same way, which may make the child’s care more difficult. C. Remain calm, efficient, professional, and sensitive.

Growth and Development
Many physical and emotional changes occur during childhood (birth to age 18). Thoughts and behaviors: Infancy: first year of life Toddler: 1 to 3 years Preschool-age: 3 to 6 years School-age: 6 to 12 years Adolescent: 12 to 18 years Lecture Outline III. Growth and Development A. Many physical and emotional changes occur during childhood. 1. Childhood extends from birth until age 18. 2. The thoughts and behaviors of children as a whole are often grouped into five stages: a. Infancy: first year of life b. Toddler: ages 1 to 3 years c. Preschool-age child: ages 3 to 6 years d. School-age child: ages 6 to 12 years e. Adolescents: ages 13 to 18 years

The Infant (1 of 7) Infancy is defined as first year of life.
First month after birth is neonatal or newborn period. 0 to 2 months Spend most time sleeping and eating Sleep up to 16 hours per day Respond mainly to physical stimuli Cannot tell the difference between parents and strangers Crying is one of the main modes of expression Lecture Outline B. The infant 1. Infancy is usually defined as the first year of life. a. The first month after birth is called the neonatal or newborn period. 2. 0 to 2 months a. Infants less than 2 months spend most of their time sleeping or eating. b. They respond mainly to physical stimuli, such as light, warmth, hunger, and sound. c. Infants sleep for up to 16 hours a day between feeding times and caregiver interactions. i. Infants should be aroused easily from a sleeping state. d. Infants cannot tell the difference between parents and strangers. e. Crying is one of the main modes of expression.

The Infant (2 of 7) 0 to 2 months (cont’d)
Basic needs: food, warmth, and comfort Soothing includes holding, cuddling, or rocking. Hearing is well developed at birth. Calm, reassuring talk is helpful in soothing. Have a sucking reflex for feeding Head control is limited Predisposed to hypothermia May need to unbundle the infant during assessment. Lecture Outline f. Their basic needs consist of food, warmth, and comfort. g. Soothing includes holding, cuddling, or rocking. h. Hearing is well developed at birth. i. Calm, reassuring talk is helpful in soothing. i. An inconsolable infant, after all obvious needs have been addressed, could be a sign of significant illness. j. Have a sucking reflex for feeding k. Head control is limited. l. Also predisposed to hypothermia m. It is often necessary to unbundle the infant during your assessment. .

The Infant (3 of 7) 2 to 6 months More active at this stage
Easier to evaluate Spend more time awake, smile and make eye contact, and recognize caregivers Have strong sucking reflex, active extremity movement, and vigorous cry May follow objects with eyes Lecture Outline 3. 2 to 6 months a. Infants at this stage are more active. i. Makes them easier to evaluate b. They spend more time awake, smile and make eye contact, and recognize caregivers. c. Will often have a strong sucking reflex, active extremity movement, and a vigorous cry. d. May follow objects with their eyes.

Increased awareness of surroundings Will use both hands to examine objects About 70% of infants will sleep through the night by 6 months. Begin to roll over at this stage Persistent crying, irritability, or lack of eye contact can be an indicator of serious illness, depressed mental status, or a delay in development. Lecture Outline e. Have increased awareness of surroundings i. Will use both hands to examine objects. f. About 70% of infants will sleep through the night by 6 months. g. Will begin to roll over at this stage. h. Persistent crying, irritability, or lack of eye contact can be an indicator of serious illness, depressed mental status, or a delay in development.

The Infant (5 of 7) 6 to 12 months Infants begin to babble.
Say their first word by their first year Learn to sit without support Begin to crawl and finally walk Predisposes age group to increased exposure to physical danger Lecture Outline 4. 6 to 12 months a. During this stage, infants begin to babble. b. By their first year, they say their first word. c. Learn to sit without support d. Begin to crawl and finally begin to walk i. Predisposes this age group to increased exposure to physical danger.

Begin teething and exploring their world by putting objects in mouth Higher risk of choking and poisonings May cry if separated from parents or caregivers Called separation anxiety Assess with caregiver nearby Persistent crying or irritability can be symptoms of serious illness. Lecture Outline e. Infants in this group also begin teething and explore their world by putting objects in their mouths. i. Higher risk for choking and poisonings f. May cry if separated from their parents or caregivers. i. Called separation anxiety ii. Assess while keeping the caregiver close by. g. Persistent crying or irritability can be a symptom of serious illness.

The Infant (7 of 7) Assessment Observe infant from a distance.
Caregiver should hold baby during physical assessment. Provide sensory comfort. Warm hands and end of stethoscope. Do painful procedures at end of assessment. Lecture Outline 5. Assessment a. Begin assessment by observing the infant from a distance. b. Let the caregiver continue to hold baby during physical assessment. i. Will avoid separation anxiety and often make the assessment easier. c. Provide as much sensory comfort as possible. i. Warm your hands and the end of the stethoscope. d. Do any painful procedures at end of the assessment process. e. Complete each procedure efficiently and avoid interruptions. f. Explain each procedure to the parent or caregiver before you perform it, because the procedure and the infant’s reaction may be upsetting.

The Toddler (1 of 4) After infancy until 3 years of age, a child is called a toddler. Experience rapid changes in growth and development 12 to 18 months Begin to walk and explore Able to open doors, drawers, boxes, and bottles Lecture Outline C. The toddler 1. After infancy, until 3 years of age, a child is called a toddler. a. Toddlers experience rapid changes in growth and development. 2. 12 to 18 months a. Toddlers begin to walk and explore during this period. i. They are able to open doors, drawers, boxes, and bottles.

The Toddler (2 of 4) 12 to 18 months (cont’d)
Because they are explorers by nature and not afraid, injuries increase. Begin to imitate behaviors of older children and parents Know major body parts May speak 4 to 6 words May not be able to fully chew food Lecture Outline b. Because they are explorers by nature and not afraid, injuries in this age group increase. c. Toddlers begin to imitate the behaviors of older children and parents. d. Know major body parts when you point to them e. May speak 4 to 6 words f. Because of a lack of molars, they may not be able to fully chew their food, leading to increased risk of choking.

The Toddler (3 of 4) 18 to 24 months
Mind develops rapidly at this stage Vocabulary increases to about 100 words. Able to name common objects Begin to understand cause and effect Balance and gait improve rapidly. Running and climbing skills develop. May cling to parents or comforting toy Use any comforting objects when available. Lecture Outline 3. 18 to 24 months a. The mind of the toddler develops rapidly. i. Vocabulary will increase from 10–15 words to about 100 words. ii. They will be able to name a common object that you point to. b. Toddlers begin to understand cause and effect. c. Balance and gait improve rapidly at this stage. i. Running and climbing skills develop. d. Toddlers at this stage tend to cling to their parents or caregivers and often have an object that comforts them. i. Use any comforting objects when available to help calm the toddler.

The Toddler (4 of 4) Assessment May have stranger anxiety
May resist separation from caregiver May have a hard time describing pain Can be distracted Begin your assessment at the feet. Persistent crying can be a symptom of serious illness or injury. Previous medical experiences may lead to hesitation toward you. Lecture Outline 4. Assessment a. May have stranger anxiety. b. May resist separation from caregiver. i. Allow them to hold any special object for comfort. c. Demonstrate the assessment on a doll or stuffed animal first if possible. i. May limit the toddler’s anxiety and make the assessment easier to perform d. May be unhappy about being restrained or held for procedures e. Toddlers can have a hard time describing or localizing pain. i. Use visual clues or Wong-Baker FACES pain scale. f. They may be distracted by a toy. g. Begin your assessment at the feet or away from the location of pain, if possible. h. Persistent crying or irritability can be a symptom of serious illness or injury. i. Previous medical experiences may lead to hesitation toward you.

The Preschool-Age Child (1 of 4)
Ages 3 to 6 years Able to use simple language effectively Most rapid increase in language occurs Can walk and run well and begin throwing, catching, and kicking during play Toilet training is mastered. Have a rich imagination and can be fearful about pain May believe injury is a result of earlier bad behavior Lecture Outline D. The preschool-age child (ages 3 to 6 years) 1. Able to use simple language effectively a. The most rapid increase in language occurs during this stage. 2. Children can walk and run well and begin throwing, catching, and kicking during play. 3. Toilet training is mastered at this stage. 4. Have a rich imagination and can be fearful about pain. a. May believe injury is a result of earlier bad behavior

Ages 3 to 6 years (cont’d) Learn which behaviors are appropriate and inappropriate Foreign body aspiration airway obstruction still high risk Assessment Can understand directions and be specific in describing painful areas Lecture Outline 5. Learn which behaviors are appropriate and which behaviors will lead to a “time out” a. Tantrums may occur. 6. Foreign body aspiration airway obstruction continues to be a high risk. 7. Assessment a. Can understand directions and be specific in describing painful areas.

Assessment (cont’d) Much history must still be obtained from caregivers. Communicate simply and directly. Appealing to child’s imagination may facilitate examination. Never lie to the patient. Patient may be easily distracted. Lecture Outline b. Despite increased ability to communicate, much of the history must still be obtained from the caregivers. c. Communicate simply and directly. d. Appealing to the child’s imagination may facilitate the examination process. e. Do not lie to a patient of this age—hard to regain lost trust. f. The patient may be easily distracted by games or a toy, or conversation.

Assessment (cont’d) Begin assessment at feet, moving to head. Use adhesive bandages to cover the site of an injection or other small wound. Modesty is developing; keep child covered as much as possible. Lecture Outline g. Begin the assessment at the feet and move toward the head. h. Use adhesive bandages to cover the site of an injection or other small wound. i. Modesty is developing, so keep the child covered as much as possible.

School-Age Years (1 of 3) 6 to 12 years
Beginning to act more like adults Can think in concrete terms Can respond sensibly to questions Can help take care of themselves School is important. Children begin to understand death. Lecture Outline E. School-age years (ages 6 to 12 years) 1. Children at this age are beginning to act more like adults. a. They can think in concrete terms. b. They can respond sensibly to questions. c. They can help take care of themselves. 2. School is important at this stage, and concerns about popularity and peer pressure begin. a. Children with chronic illness or disabilities can become self-conscious about fitting in. 3. At this stage, children begin to understand death is final, but their understanding of what death is and why it occurs is still unrealistic. a. May increase anxiety about illness and injury.

School-Age Years (2 of 3) Assessment
Assessment begins to be more like adults’. To help gain trust, talk to the child, not just the caregiver. Start with head and move to the feet. If possible, give the child choices. Ask only the type of questions that let you control the answer. Do not bargain or debate with the patient. Lecture Outline 4. Assessment a. Assessment begins to be more like an adult assessment. b. To help gain trust, talk to the child, not just the caregiver. c. The child is probably familiar with the process of a physical exam. i. May or may not make the assessment easier depending on the child’s experiences d. Start with head and work toward the feet, as in an adult assessment. e. If possible, give the child choices. For example: i. Would you like to sit up or lie down? ii. Would you like to take off your clothes yourself? f. Ask only the type of questions that let you control the answer. For example: i. Would you like this cuff to hug your right or left arm? ii. Do not bargain or debate with the patient.

School-Age Years (3 of 3) Assessment (cont’d)
Allow the child to listen to his or her heartbeat through the stethoscope. Can understand the difference between physical and emotional pain Provide simple explanations about what is causing their pain and what will be done. Ask the parent’s or caregiver’s advice about which distraction will work best. Lecture Outline g. Allow the child to listen to his or her own heartbeat through the stethoscope. h. These children can understand the difference between physical and emotional pain. i. Give them simple explanations about what is causing their pain and what will be done about it. j. Ask the parent’s or caregiver’s advice about which distraction will work best.

Adolescents (1 of 5) 13 to 18 years
Able to think abstractly and can participate in decision making Personal morals begin to develop. Able to discriminate between right and wrong Able to incorporate values into decision making Physically similar to adults Shifting from family to friends for support Interest in romantic relationships begins Lecture Outline F. Adolescents (ages 13 to 18 years) 1. Most adolescents are able to think abstractly and can participate in decision making. a. Personal morals begin to develop. b. Are able to discriminate between what is right and wrong c. Are able to incorporate their own values and beliefs into their daily decision-making process 2. Physically similar to adults, but they are still children on the emotional level. a. Gradually shift from relying on family to relying on friends for psychologic support, social development, and acceptance from their peers. b. Interest in romantic relationships begins.

Adolescents (2 of 5) 12 to 18 years (cont’d) Puberty begins.
Very concerned about body image and appearance Strong feelings about privacy Time of experimentation and risk-taking Often feel “indestructible” Struggle with independence, loss of control, body image, sexuality, and peer pressure May have mood swings or depression Lecture Outline c. This is the stage when puberty begins. i. Makes the adolescent very concerned about body image and appearance ii. Injuries or illnesses can be over- or underexpressed due to feelings about body image or fear of disfigurement. iii. May dislike being observed during procedures and have strong feelings about privacy d. Adolescence is a time of experimentation and risk-taking behaviors. i. Adolescents often feel “indestructible.” ii. They struggle with independence, loss of control, body image, sexuality, and peer pressure. iii. They may have mood swings or depression, or when ill/injured, may act younger than their age.

Adolescents (3 of 5) Assessment
Can often understand complex concepts and treatment options Allow them to be involved in their own care. Provide choices, while lending guidance. EMT of same gender should do physical examination, if possible. Lecture Outline 3. Assessment a. Adolescents can often understand very complex concepts and treatment options. i. Provide them with information when they request it. b. Allow adolescents to be involved in their own care. i. Provide choices, while lending guidance. c. An EMT of the same gender should perform the physical examination, if possible, to lessen the stress of the event.

Adolescents (4 of 5) Assessment (cont’d)
Allow them to speak openly and ask questions. Risk-taking behaviors are common. Can ultimately facilitate development and judgment, and shape identity Can also result in trauma, dangerous sexual practices, and teen pregnancy Lecture Outline d. Allow the adolescent to speak openly and ask questions. e. Risk-taking behaviors are common at this age. i. Some risks can ultimately facilitate development and judgment and shape their identity as an adult. ii. Risks can also result in unintentional trauma, drug and/or alcohol abuse, unprotected sex, and teen pregnancy.

Adolescents (5 of 5) Assessment (cont’d)
Female patients may be pregnant. Important to report this information to receiving facility. Adolescent may not want parents to know this information. Try to interview without the caregiver/parent present. Have clear understanding of pain Get them talking to distract them Lecture Outline f. Female patients may be pregnant. i. Important to report this information to the receiving facility ii. Adolescent may not want parents to know this information. (a) Try to interview the adolescent without the caregiver present if you suspect she is withholding information. g. Adolescents have a clear understanding of the purpose and meaning of pain. i. Explain necessary procedures in advance. ii. Assess level of pain by observing facial and body expression as well as by asking. iii. To distract them, find out some of their interests and get them talking.

Anatomy and Physiology
Body is growing and changing very rapidly during childhood. You must understand the physical differences between children and adults and alter your patient care accordingly. Lecture Outline IV. Anatomy and Physiology A. The body is growing and changing rapidly during childhood. 1. You must understand the physical differences between children and adults and alter your patient care accordingly.

The Respiratory System (1 of 7)
Anatomy of airway differs from adults. Pediatric airway is smaller in diameter and shorter in length. Lungs are smaller. Heart is higher in child’s chest. Lecture Outline B. The respiratory system 1. Anatomy of pediatric airway differs from adults. a. Pediatric airway is smaller in diameter and shorter in length. b. Lungs are smaller. c. Heart is higher in a child’s chest. © Jones & Bartlett Learning.

Anatomy of airway differs from adults (cont’d). Glottic opening is higher and positioned more anteriorly, and neck appears to be nonexistent. As child develops, the neck becomes proportionally longer as the vocal cords and epiglottis achieve anatomically correct adult position. Lecture Outline d. Glottic opening is higher and positioned more anteriorly, and the neck appears to be nonexistent. e. As children develop, the neck gets proportionally longer as the vocal cords and epiglottis achieve anatomically correct adult position.

Anatomy of airway differs from adult (cont’d). Larger, rounder occiput Proportionally larger tongue Long, floppy, U-shaped epiglottis Less-developed rings of cartilage in the trachea Narrowing, funnel-shaped upper airway Lecture Outline f. Occiput is larger and rounder, which requires more careful positioning of the airway. g. Tongue is larger relative to the size of the mouth and in a more anterior location in the mouth. Child’s tongue can easily block the airway. h. Long, floppy, U-shaped epiglottis in infants and toddlers is larger than adult’s. i. Rings of cartilage in the trachea are less developed and may easily collapse if the neck is flexed or hyperextended. j. The upper airway has a narrowing funnel shape compared to the cylinder shape of the lower airway.

Anatomy of airway differs from adult (cont’d). Diameter of trachea in infants is about the same as a drinking straw. Airway is easily obstructed by secretions, blood, or swelling. Infants are nose breathers and may require suctioning and airway maintenance. Respiratory rate of 20 to 60 breaths/min is normal for a newborn. Lecture Outline k. Diameter of trachea in infants is about the same as a drinking straw. i. Airway is easily obstructed by secretions, blood, or swelling. ii. Infants are nose breathers and may require suctioning and airway maintenance. iii. A respiratory rate of 30 to 60 breaths/min is normal for a newborn. iv. A respiratory rate of 12 to 20 breaths/min is normal for a teenager.

Anatomy of airway differs from adult (cont’d). Children have an oxygen demand twice that of an adult. Increases risk for hypoxia Lecture Outline l. Children have an oxygen demand twice that of an adult. i. This higher demand combined with a smaller oxygen reserve increases the risk of hypoxia.

Anatomy of airway differs from adult (cont’d). Muscles of diaphragm dictate the amount of oxygen a child inspires. Pressure on child’s abdomen can cause respiratory compromise. Use caution when applying the straps of a spinal immobilization device. Lecture Outline m. The muscles of the diaphragm dictate the amount of oxygen a child inspires. i. Anything that places pressure on the abdomen of a young child can block the movement of the diaphragm and cause respiratory compromise. ii. Must use caution when applying the straps of a spinal immobilization device because it may hinder the tidal volume.

Anatomy of airway differs from adult (cont’d). Gastric distention can interfere with movement of the diaphragm and lead to hypoventilation. Breath sounds are more easily heard in children because of their thinner chest walls. Detection of poor air movement or complete absence of breath sounds may be more difficult. Lecture Outline n. Gastric distention can interfere with movement of the diaphragm and lead to hypoventilation. o. Breath sounds are more easily heard because of their thinner chest walls. p. Less air is exchanged with each breath, so detection of poor air movement or complete absence of breath sounds may be more difficult.

The Circulatory System (1 of 2)
Important to know normal pulse ranges Infants heart can beat 160 beats/min or more. Primary method used to compensate for decreased perfusion Children are able to compensate for decreased perfusion by constricting the vessels in the skin. Blood flow to the extremities can be diminished. Signs of vasoconstriction include pallor (early sign), weak distal pulses in the extremities, delayed capillary refill, and cool hands or feet. Lecture Outline C. The circulatory system 1. Important to know the normal pulse ranges when evaluating children. a. An infant’s heart can beat 160 times or more per minute. i. This is the primary method the body uses to compensate for decreased perfusion. b. Children are able to compensate for decreased perfusion by constricting the vessels in the skin. i. Blood flow to the extremities can be diminished. c. Signs of vasoconstriction include pallor (early sign), weak distal pulses in the extremities, delayed capillary refill, and cool hands or feet.

The Circulatory System (2 of 2)
The table on this slide lists responsive pediatric pulse rates. Data From: Pediatric Advanced Life Support, 2012, the American Heart Association.

The Nervous System (1 of 2)
Pediatric nervous system is immature, underdeveloped, and not well protected. Head-to-body ratio is larger. Occipital region of head is larger. Subarachnoid space is relatively smaller, leaving less cushioning for brain. Brain tissue and cerebral vasculature are fragile and prone to bleeding from shearing forces. Lecture Outline D. The nervous system 1. Compared to an adult nervous system, the pediatric nervous system is immature, underdeveloped, and not well protected. a. Head-to-body ratio of infant and young child is disproportionately larger. i. More prone to head injuries from falls or motor vehicle crashes b. Occipital region of the head is larger, which increases the momentum of the head during a fall. c. The subarachnoid space is relatively smaller, leaving less cushioning for the brain. d. The brain tissue and cerebral vasculature are fragile and prone to bleeding from shearing forces. i. Such as during an incidence of shaken baby syndrome

The Nervous System (2 of 2)
Pediatric brain requires higher cerebral blood flow, oxygen, and glucose. At risk for secondary brain damage from hypotension and hypoxic events Spinal cord injuries are less common. If injured, it is more likely to be an injury to the ligaments because of a fall. For suspected neck injury, perform manual in-line stabilization or follow local protocols. Lecture Outline 2. Pediatric brain also requires a higher amount of cerebral blood flow, oxygen, and glucose than does adult brain tissue. a. This means that the pediatric brain is at risk for secondary brain damage from hypotension and hypoxic events. 3. Spinal cord injuries are less common in pediatric patients. a. If cervical spine is injured, it is more likely to be an injury to the ligaments because of a fall. b. For suspected neck injury, perform manual in-line stabilization or follow local protocols.

The Gastrointestinal System
Abdominal muscles are less developed. Less protection from trauma Liver, spleen, and kidneys are proportionally larger and situated more anteriorly and close to one another. Prone to bleeding and injury There is a higher risk for multiple organ injury. Lecture Outline E. The gastrointestinal system 1. Abdominal muscles are less developed in pediatric patients. a. Less protection from trauma. b. Liver, spleen, and kidneys are proportionally larger and situated more anteriorly, so they are prone to bleeding and injury. i. Because organs are positioned closer to each other, there is a higher risk for multiple organ injury caused by minimal direct impact.

The Musculoskeletal System (1 of 3)
Open growth plates allow bones to grow. As a result of growth plates, children’s bones are softer and more flexible, making them prone to stress fracture. Bone length discrepancies can occur if injury to growth plate occurs. Immobilize all strains and sprains. Lecture Outline F. The musculoskeletal system 1. Open growth plates allow bones to grow during childhood. a. As a result of open growth plates, children’s bones are softer and more flexible, making them prone to stress fractures. b. Bone length discrepancies can occur if there is injury to a growth plate. i. Important to immobilize extremities with sprains and strains because they may actually be stress fractures.

Bones of an infant’s head are flexible and soft. Soft spots are located at front and back of head. Referred to as fontanelles Will close at particular stages of development Fontanelles of an infant can be a useful assessment tool. Lecture Outline 2. The bones of an infant’s head are flexible and soft. a. Soft spots are located at the front and back of the head. i. Referred to as fontanelles ii. Will close at particular stages of development iii. Fontanelles of an infant can be a useful assessment tool. (a) Bulging fontanelles can indicate increased intracranial pressure. (b) Sunken fontanelles can indicate dehydration.

Thoracic cage is highly elastic and pliable. Composed of cartilaginous connective tissue Ribs and vital organs are less protected. Lecture Outline 3. The thoracic cage in children is highly elastic and pliable because it is primarily composed of cartilaginous connective tissue. a. The ribs and vital organs are less protected by muscle and fat.

The Integumentary System
Pediatric system differs in a few ways: Thinner skin and less subcutaneous fat Composition of skin is thinner and tends to burn more deeply and easily with less exposure. Higher ratio of body surface area to body mass leads to larger fluid and heat losses. Lecture Outline G. The integumentary system 1. The integumentary system of the pediatric population differs in a few ways: a. The skin is thinner with less subcutaneous fat. b. Composition of skin is thinner and tends to burn more deeply and easily than an adult’s. c. Higher ratio of body surface area to body mass can lead to larger fluid and heat losses.

Scene Size-up (1 of 4) Assessment begins at time of dispatch.
Prepare mentally for approaching and treating an infant or child. Plan for pediatric size-up, equipment, and age-appropriate physical assessment. Collect age and gender of child, location of scene, NOI or MOI and chief complaint from dispatch. Lecture Outline IV. Patient Assessment A. Scene size-up 1. Assessment begins at the time of initial dispatch. a. Prepare mentally for approaching and treating an infant or child. b. Plan for pediatric scene size-up, pediatric equipment, and age-appropriate physical assessment. c. If possible, collect age and gender of child, location of the scene, NOI or MOI, and chief complaint from dispatch.

Scene Size-up (2 of 4) Scene safety
Ensure proper safety precautions and standard precautions. Note position in which patient is found. Look for possible safety threats. Patient may be safety threat if he or she has infectious disease. Lecture Outline 2. Scene safety a. Ensure appropriate safety precautions and standard precautions have been taken. b. Note the position in which the patient is found. c. Look for possible safety threats to the child, parents or caregivers, bystanders, or EMS providers. d. Patient may be a safety threat if they have an infectious disease.

Scene Size-up (3 of 4) Scene safety (cont’d)
Do an environmental assessment. Will provide important information Inspect physical environment. Information from parents or caregivers is important and may provide clues to the patient’s problem. Document dangerous scene conditions and inappropriate statements from caregivers. Lecture Outline e. Next, do an environmental assessment. i. Will give important information on the chief complaint, number of patients, MOI or NOI, and ongoing health risks. ii. Inspect the physical environment and interactions with caregivers/family. iii. Information from parents or caregivers is important and may provide clues to the patient’s problem. (a) Document dangerous scene conditions and inappropriate statements from caregivers.

Scene Size-up (4 of 4) Traumatic scene where the child is unresponsive or too young to communicate Assume the injury was significant enough to cause head or neck injuries. Perform cervical spine immobilization if suspected MOI is severe. Pad under the child’s head and/or shoulder to facilitate a neutral position for airway management. Lecture Outline 3. Traumatic scene where the child is unresponsive or too young to communicate a. Assume the injury was significant enough to cause head or neck injuries. b. Perform cervical spine immobilization if you suspect the MOI to be severe. i. Remember to pad under the child’s head and/or shoulder to facilitate a neutral position for airway management.

Primary Assessment (1 of 18)
Form a general impression. Use pediatric assessment triangle (PAT). Does not require you to touch the patient Can be performed in less than 30 seconds Used with permission of the American Academy of Pediatrics, Pediatric Education for Preshospital Professionals, © American Academy of Pediatrics, 2000. Lecture Outline B. Primary assessment 1. The objective of the primary assessment is to identify and treat immediate or potential threats to life. 2. Pediatric Assessment Triangle (PAT) a. Use the pediatric assessment triangle to determine if the patient is sick or not sick. i. The PAT is structured assessment tool that allows you to rapidly form a general impression without touching the patient. (a) Can be performed in less than 30 seconds

PAT Does not require equipment Three steps: Appearance Work of breathing Circulation Lecture Outline ii. PAT consists of three elements and requires no equipment: (a) Appearance (muscle tone and mental status) (b) Work of breathing (c) Circulation to the skin

Appearance Note LOC, interactiveness, and muscle tone. You can use the AVPU scale, modified as necessary for the pediatric patient’s age. Normal level of consciousness: act appropriately for age, exhibit good muscle tone, and maintain good eye contact TICLS mnemonic helps determine if patient is sick or not sick: Tone, Interactiveness, Consolability, Look or gaze, Speech or cry Lecture Outline b. Appearance i. Note the level of consciousness or interactiveness and muscle tone. ii. You can also evaluate the pediatric patient’s level of consciousness by using the AVPU scale, modified as necessary for the pediatric patient’s age. iii. An infant or child with a normal level of consciousness will act appropriately for his or her age, exhibiting good muscle tone and maintaining good eye contact. iv. Poor muscle tone or poor eye contact can mean an abnormal level of consciousness. v. TICLS mnemonic can help determine if the patient is sick: (a) Tone (b) Interactiveness (c) Consolability (d) Look or gaze (e) Speech or cry

Work of breathing Increases as the body attempts to compensate for abnormalities in oxygenation and ventilation May manifest as abnormal airway noise, accessory muscle use, retractions, head bobbing, nasal flaring, tachypnea, and tripod position. Lecture Outline c. Work of breathing i. Increases as the body attempts to compensate for abnormalities in oxygenation and ventilation. ii. Increased work of breathing often manifests as: (a) Abnormal airway noise (b) Accessory muscle use (c) Retractions of the intercostal muscles or sternum (d) Head bobbing (e) Nasal flaring (f) Tachypnea: Increased respiratory rate (g) Tripod position: In older children, this position will maximize the effectiveness of the airway.

Circulation to the skin When cardiac output fails, the body shunts blood from areas of lesser need to areas of greater need. Pallor of skin and mucous membranes may be seen in compensated shock. Mottling is sign of poor perfusion. Cyanosis reflects decreased level of oxygen. Lecture Outline d. Circulation to the skin i. When cardiac output fails, the body shunts blood from areas of lesser need (such as skin) to areas of greater need (such as brain, heart, and kidneys). ii. Pallor of the skin and mucous membranes may be seen in compensated shock. (a) May also be a sign of anemia or hypoxia iii. Mottling is another sign of poor perfusion. iv. Cyanosis reflects a decreased level of oxygen in the blood. (a) Is a late sign of respiratory failure or shock (b) Never wait for the development of cyanosis before administering oxygen.

From PAT findings, you will decide if the patient is stable or requires urgent care. If unstable, assess ABCs, treat life threats, and transport immediately. With life-threatening external hemorrhage, assess and address the CABs first, including tourniquets. If stable, continue with the remainder of the assessment process. Lecture Outline e. From the PAT findings, you will decide if the pediatric patient is stable or requires urgent care. i. If the patient is unstable, assess the ABCs, treat any life threats, and transport immediately. (a) With obvious life-threatening external hemorrhage, assess and address the CABs first, including tourniquets for arterial hemorrhage from extremities. ii. If the patient is stable, continue with the remainder of the patient assessment process, perform necessary interventions, and discuss transport options with the parents or caregivers.

Hands-on ABCs For pediatric patient you will now perform a hands-on ABCs assessment. Assess and treat any life threats as you identify them by following the ABCDE format Airway Breathing Circulation Disability Exposure Lecture Outline 3. Hands-on ABCs a. Next, you will perform a hands-on ABCs assessment. b. Assess and treat any life threats as you identify them by following the ABCDE format: i. Airway ii. Breathing iii. Circulation iv. Disability v. Exposure

Airway If airway is open and will remain open, assess respiratory adequacy. If patient is unresponsive or has difficulty keeping airway open, ensure it is properly positioned and clear of mucus, vomitus, blood, and foreign bodies. Use head tilt–chin lift or jaw-thrust maneuver to open airway. Lecture Outline c. Airway i. If airway is open and patient can adequately keep it open, assess respiratory adequacy. ii. If patient is unresponsive or has difficulty keeping the airway clear, ensure that it is properly positioned and that it is clear of mucus, vomitus, blood, and foreign bodies. (a) If trauma has been ruled out, use head tilt–chin lift to open the airway. (b) If trauma is suspected, use the jaw-thrust maneuver to open the airway.

Airway (cont’d) Always position airway in neutral sniffing position. Keeps trachea from kinking Maintains proper alignment Establish whether patient can maintain his or her own airway. Lecture Outline iii. Always position the airway in a neutral sniffing position (see Skill Drill 34-1). (a) Keeps the trachea from kinking (b) Maintains proper alignment should you have to immobilize the spine iv. Establish whether the patient can maintain his or her own airway.

Breathing Use the look, listen, feel technique. Place both hands on patient’s chest to feel for rise and fall of chest wall. Belly breathing in infants is considered adequate. Bradypnea is an ominous sign and indicates impending respiratory arrest. Lecture Outline d. Breathing i. Look, listen, feel technique ii. Place both hands on the patient’s chest to feel for the rise and fall of the chest wall. iii. Belly breathing in infants is considered adequate because of the soft pliable bones of the chest and the strong muscular diaphragm. iv. Bradypnea (decrease in respiratory rate) is an ominous sign and indicates impending respiratory arrest.

Circulation Determine if patient has a pulse, is bleeding, or is in shock. In infants, palpate brachial or femoral pulse. In children older than 1 year, palpate carotid pulse. Strong central pulses usually indicate that the child is not hypotensive. Lecture Outline e. Circulation i. Must determine if the patient has a pulse, is bleeding, or is in shock. (a) Infants and children can tolerate only a small amount of blood loss before circulatory compromise occurs. ii. In infants, palpate the brachial pulse or femoral pulse. iii. In children older than 1 year, palpate the carotid pulse. iv. Strong central pulses usually indicate that the child is not hypotensive.

Circulation (cont’d) Weak or absent peripheral pulses indicate decreased perfusion. Tachycardia may be early sign of hypoxia. Interpret pulse within the context of overall history, the PAT, and primary assessment. Evaluate trend of increasing or decreasing pulse rate. Feel skin for temperature and moisture. Estimate the capillary refill time. Lecture Outline v. Weak or absent peripheral pulses indicate decreased perfusion. (a) Absence of a central pulse indicates the need for CPR. vi. Tachycardia may be an early sign of hypoxia or shock or a less serious condition such as fever, anxiety, pain, or excitement. vii. Interpret the pulse within the context of the overall history, the PAT, and primary assessment. viii. A trend of an increasing or decreasing pulse rate may suggest worsening hypoxia or shock or improvement after treatment. (a) When hypoxia or shock becomes critical, bradycardia occurs. (b) Bradycardia in a pediatric patient often indicates impending cardiopulmonary arrest. ix. Feel the skin for temperature and moisture. x. Estimate the capillary refill time. (a) Color should return within 2 seconds.

Disability Use AVPU scale or pediatric GCS. Check pupil response. Look for symmetric movement of extremities. Pain is present with most types of injuries. Assessment of pain must consider developmental age of patient. Lecture Outline f. Disability i. Use the AVPU scale or the pediatric Glasgow Coma Scale to assess level of consciousness. ii. Check the responses of pupils. (a) A normal pupil constricts after a light stimulus. (b) Pupillary response may be abnormal in the presence of drugs, ongoing seizures, hypoxia, or brain injury. iii. Look for symmetric movement of the extremities. iv. Pain is present with most types of injury. (a) Inadequate treatment of pain has many adverse effects on the pediatric patient and the family. v. Assessment of pain must take into consideration the developmental age of the patient. (a) The ability to recognize pain will improve as the patient becomes older. (b) The Wong-Baker FACES Scale is helpful in assessing level of pain.

Exposure Hands-on ABCs require that the caregiver remove some of patient’s clothing for observation. Avoid heat loss by covering the patient as soon as possible. More prone to hypothermic events Should be kept warm during transport Lecture Outline g. Exposure i. The hands-on ABCs require that the caregiver remove part of the pediatric patient’s clothing to allow observation of the face, chest wall, and skin. (a) Be careful to avoid heat loss by covering the patient as soon as possible. ii. Pediatric population is more prone to hypothermic events due to immature thermoregulatory system, thinner skin, and a lack of subcutaneous fat. (a) Infants younger than 6 months lack the ability to shiver in response to cold. (b) Newborns and infants less than 1 month are the most susceptible to hypothermia. iii. Infants and young children should be kept warm during transport or when the patient is exposed to assess or reassess an injury. (a) Cover the head: Up to 50% of heat loss can occur with a head that is larger in proportion to the rest of the body.

Transport decision Determine whether rapid transport to the hospital is indicated. Rapid transport indicated if: Significant MOI History compatible with serious illness Physical abnormality noted Potentially serious anatomic abnormality Significant pain Abnormal level of consciousness Lecture Outline 4. Transport decision a. Determine whether rapid transport to the hospital is indicated. i. If the pediatric patient is in stable condition, obtain a patient history, perform a secondary assessment at the scene, transport, and provide additional treatment as needed. ii. Rapid transport is indicated if any of the following conditions exist: (a) A significant MOI with the addition of: (1) Any fall from a height equal to or greater than a pediatric patient’s height, especially with a headfirst landing (2) Bicycle crash (b) A history compatible with a serious illness (c) A physical abnormality noted during the primary assessment (d) A potentially serious anatomic abnormality (e) Significant pain (f) Abnormal level of consciousness, AMS, and/or any signs or symptoms of shock

Transport decision (cont’d) Also consider: Type of clinical problem Benefits or ALS treatment in field Local EMS protocol Your comfort level Transport time to hospital If patient’s condition is urgent, initiate immediate transport to the closest appropriate facility. Lecture Outline b. Also consider the following when making a transport decision: i. The type of clinical problem. ii. The expected benefits of ALS treatment in the field. iii. Local EMS system treatment and transport protocols. iv. Your comfort level. v. Transport time to the hospital. c. If the pediatric patient’s condition is urgent, then initiate immediate transport to the closest appropriate facility. d. Specialty facilities such as trauma centers or children’s hospitals have the training, staff, and equipment to provide complete care for all levels of pediatric patients. e. The most appropriate facility is not always the closest. Ask yourself: i. Can I deliver the pediatric patient to the most appropriate facility without risk or delay to the pediatric patient? ii. If the answer is no, transport the pediatric patient to the closest facility.

Transport decision (cont’d) Less than 40 lb, transport in car seat To mount a car seat to a stretcher: Put head of stretcher upright. Put car sear against the back of stretcher. Secure upper and lower stretcher straps through seatbelt holes on car seat. Push seat into stretcher tightly and retighten straps. Lecture Outline f. Pediatric patients weighing less than 40 pounds who do not require spinal immobilization should be transported in a car seat. i. A seat should be chosen to fit the appropriate weight of the pediatric patient. g. To mount a car seat to a stretcher: i. Place the head of the stretcher in an upright position. ii. Place the seat so it is against the back of the stretcher. iii. Secure one of the stretcher straps from the upper portion of the stretcher through the seatbelt positions on the car seat and strap it tightly to the stretcher. iv. Repeat on the lower portion of the stretcher. v. Push the car seat into the stretcher tightly and retighten the straps.

Transport decision (cont’d) Follow manufacturer’s instructions to secure car seat in captain’s chair. Patients who require spinal immobilization: immobilize on long board or other suitable spinal immobilization device. Patients in cardiopulmonary arrest: use a device that can be secured to the stretcher. You should not use the pediatric patient’s own car seat. The goal is to secure and protect the pediatric patient for transport in the ambulance. Lecture Outline h. Follow the seat manufacturer’s instructions to secure a car seat to a captain’s chair. i. Patients younger than 2 years must be transported in a rear-facing position because of the lack of mature neck muscles. i. For pediatric patients who require spinal immobilization, the patient should be immobilized on a long board or other suitable spinal immobilization device. j. Pediatric patients in cardiopulmonary arrest should be on a device that can be secured to the stretcher. k. You should not use the pediatric patient’s own car seat. l. The goal is to secure and protect the pediatric patient for transport in the ambulance.

History Taking (1 of 4) Approach to history depends on age of patient.
History information for an infant, toddler, or preschool-age child will be obtained from caregiver. Adolescent information is obtained from patient. Questioning the parents or child about the immediate illness or injury should be based on the child’s chief complaint. Lecture Outline C. History taking 1. Your approach to the history will depend on the age of the pediatric patient. a. Historical information for an infant, toddler, or preschool-age child will have to be obtained from the parent or caregiver. b. When dealing with an adolescent, most information will be obtained from the patient. i. Sexual activity, possibility of pregnancy, and drug or alcohol use should be obtained from patient in private. c. Questioning of the parents or child about the immediate illness or injury should be based on the child’s chief complaint.

History Taking (2 of 4) Questions to ask based on chief complaint:
NOI or MOI Length of sickness or injury Key events leading up to injury or illness Presence of fever Effects of illness or injury on behavior Patient’s activity level Recent eating, drinking, and urine output Lecture Outline d. When interviewing the parent/caregiver or older child about the chief complaint, obtain the following: i. NOI or MOI ii. How long the pediatric patient has been sick or injured iii. The key events leading to the injury or illness iv. Presence of fever v. Effects of the illness of injury on the pediatric patient’s behavior vi. Pediatric patient’s activity level vii. Recent eating, drinking, and urine output

History Taking (3 of 4) Questions to ask (cont’d)
Changes in bowel or bladder habits Presence of vomiting, diarrhea, abdominal pain Presence of rashes Obtain name and phone number of caregiver if they are not able to come to the hospital with you. Lecture Outline viii. Change in bowel or bladder habits ix. Presences of vomiting, diarrhea, abdominal pain x. Presence of rashes e. Obtain name and phone number of caregiver if they are not able to come to the hospital with you.

History Taking (4 of 4) SAMPLE history Obtaining OPQRST
Same as adult’s Questions based on age and developmental stage Obtaining OPQRST Same for children and adults Lecture Outline 2. SAMPLE history a. SAMPLE history for pediatric patient is the same as an adult’s. b. The process for obtaining OPQRST is the same for children and adults. c. Questions should be based on pediatric patient’s age and developmental stage of life.

Secondary Assessment (1 of 11)
Physical examinations Secondary assessment of the entire body should be used when patient is unresponsive or has significant MOI. Use the DCAP-BTLS mnemonic. Focused assessments should be performed on patients without life threats. Focus on areas of body affected by injury or illness as well as on the chief complaint, MOI or NOI, and the findings of the primary assessment. Lecture Outline D. Secondary assessment 1. Physical examinations a. A secondary assessment of the entire body should be used when pediatric patients have the potential for hidden illnesses or injuries (unresponsive or have a significant MOI). b. May help identify problems that were not as obvious during the primary assessment, but over time, the presenting signs and symptoms have become more apparent. i. Use the DCAP-BTLS mnemonic: Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling. c. A focused assessment should be performed on pediatric patients without life-threatening illnesses or injuries. i. Focus your physical examination on the area(s) of the body affected by the illness or injury as well as on the chief complaint, MOI or NOI, and the findings of the primary assessment.

Physical examinations (cont’d) Infants, toddlers, and preschool-age children should be assessed started at the feet and ending at the head. School-aged children and adolescents should be assessed using the head-to-toe approach. Lecture Outline d. Infants, toddlers, and preschool-age children who do not have life-threatening illness or injuries should be assessed starting at the feet and ending at the head. e. School-age children and adolescents can be assessed using the head-to-toe approach.

Physical examinations (cont’d) Head Look for bruising, swelling, and hematomas. Assess fontanelles in infants. Nose Nasal congestion and mucus can cause respiratory distress. Gentle bulb or catheter suction may bring relief. Lecture Outline f. Physical examination may include the following: i. Head (a) The younger the patient, the larger the head is in proportion to the rest of the body. (b) Look for bruising, swelling, and hematomas. (1) Significant blood loss can occur between the skull and scalp of an infant. (c) A tense or bulging fontanelle in an upright, noncrying infant suggests elevated intracranial pressure caused by meningitis, encephalitis, or intracranial bleeding. (d) A sunken fontanelle suggests dehydration. ii. Nose (a) Young infants are obligate nose breathers, so nasal congestion with mucus can cause respiratory distress. (b) Gentle bulb or catheter suction of the nostrils may bring relief.

Physical examinations (cont’d) Ears Drainage from ears may indicate skull fracture. Battle sign may indicate skull fracture. Presence of pus may indicate infection. Mouth Look for active bleeding and loose teeth. Note the smell of the breath. Lecture Outline iii. Ears (a) Look for drainage from the ear canals. (1) Leaking blood suggests a skull fracture. (b) Check for bruises behind the ears or Battle sign. (1) Late sign of skull fracture (c) Presence of pus may indicate an ear infection or perforation of the ear drum. iv. Mouth (a) In the trauma patient, look for active bleeding and loose teeth. (b) Note the smell of the breath.

Physical examinations (cont’d) Neck Examine tracheal area for swelling or bruising. Note if patient cannot move neck and has high fever. Chest Examine for penetrating trauma, lacerations, bruises, or rashes. Feel clavicles and every rib for tenderness and/or deformity. Lecture Outline v. Neck (a) Examine the area near the trachea for swelling or bruising. (b) Note if pediatric patient cannot move neck and has a high fever, as this may indicate bacterial or viral meningitis. vi. Chest (a) Examine the chest for penetrating injuries, lacerations, bruises, or rashes. (b) If the patient is injured, feel the clavicles and every rib for tenderness and/or deformity.

Physical examinations (cont’d) Back Inspect back for lacerations, penetrating injuries, bruises, or rashes. Abdomen Inspect for distention. Gently palpate and watch for guarding or tensing of muscles. Note tenderness or masses. Look for seat belt abrasions or bruising. Lecture Outline vii. Back (a) Inspect the back for lacerations, penetrating injuries, bruises, or rashes. viii. Abdomen (a) Inspect the abdomen for distention. (b) Gently palpate the abdomen and watch for guarding or tensing of abdominal muscles, which could suggest infection, obstruction, or intra-abdominal injury. (c) Note any tenderness or masses. (d) Look for any seat belt abrasions or bruising.

Physical examinations (cont’d) Extremities Assess for symmetry. Compare both sides for color, warmth, size of joints, swelling, and tenderness. Put each joint through a full range of motion while watching the patient’s eyes for signs of pain. Lecture Outline ix. Extremities (a) Assess for symmetry. (b) Compare both sides for color, warmth, size of joints, swelling, and tenderness. (c) Put each joint through a full range of motion while watching the eyes for signs of pain.

Vital signs Some guidelines/equipment used to assess adult circulatory status have limitations in pediatric patients. Normal heart rates vary with age in pediatric patients. Blood pressure is usually not assessed in patients younger than 3 years. Lecture Outline 2. Vital signs a. Some of the guidelines used to assess adult circulatory status have important limitations in pediatric patients. i. Normal heart rates vary with age in pediatric patients. ii. Blood pressure is usually not assessed in pediatric patients younger than 3 years. (a) Offers little information about the patient’s circulatory status and is difficult to obtain.

Vital signs (cont’d) Assessment of skin is a better indication of pediatric patient’s circulatory status. When equipment is used, it is important to use appropriately sized equipment. Use a cuff that covers two thirds of the pediatric patient’s upper arm. Lecture Outline b. Assessment of the skin is a better indication of a pediatric patient’s circulatory status. c. It is important to use appropriately sized equipment when assessing a pediatric patient’s vital signs. i. To obtain accurate blood pressure reading, use a cuff that covers two thirds of the pediatric patient’s upper arm. (a) Cuff that is too small will give a falsely high reading. (b) Cuff that is too large will give a falsely low reading.

Vital signs (cont’d) Use this formula to determine blood pressure for children ages 1–10 years: 70 + (2 × child’s age in years) = systolic blood pressure Respiratory rates may be difficult to interpret. Count respirations for at least 30 seconds and double that number. In infants and those younger than 3 years, evaluate respirations by assessing the rise and fall of the abdomen. Lecture Outline d. The formula 70 + (2 × child’s age in years) = systolic blood pressure is a useful tool to determine blood pressure in children 1 to 10 years of age. e. Respiratory rates may be difficult to interpret. i. Count the respirations for at least 30 seconds and then double that number (if counted for 30 seconds). ii. In infants and children younger than 3 years, evaluate respirations by assessing the rise and fall of the abdomen.

Vital signs (cont’d) Assess pulse rate by counting at least 1 minute, noting quality and regularity Normal pediatric vital signs vary with age. Assess respirations, then pulse, then blood pressure. Evaluate pupils using a small pen light. Compare size of the pupils. Pulse oximeter is a valuable tool for patients with respiratory issues. Lecture Outline f. Assess the pulse rate by counting at least 1 minute, noting quality and regularity. g. Normal vital signs in pediatric patients vary with age. i. Assess respirations and then pulse, and assess blood pressure last. (a) Warm stethoscope before placing it on the skin. h. Evaluate pupils using a small penlight. i. Compare the size of the pupils against each other. i. A pulse oximeter is a valuable tool to measure the oxygen saturation in a pediatric patient with respiratory issues.

Reassessment (1 of 2) Reassess the pediatric patient’s condition as necessary. Obtain vitals every 15 minutes if stable. Obtain vitals every 5 minutes if unstable. Continually monitor respiratory effort, skin color and condition, and level of consciousness or interactiveness. Lecture Outline E. Reassessment 1. Reassess the pediatric patient’s condition as necessary. a. Obtain vital signs every 15 minutes for a child in stable condition. b. Obtain vital signs every 5 minutes for a child in unstable condition. c. Continually monitor respiratory effort, skin color and condition, and level of consciousness or interactiveness. i. Repeat the primary assessment and adjust your treatment accordingly.

Reassessment (2 of 2) Interventions Communication and documentation
Parents or caregivers may be able to assist. Able to calm and reassure child Often well versed on their child’s medical conditions Oxygen or nebulizer administration Communication and documentation Communicate and document all relevant information to ED personnel. Lecture Outline 2. Interventions a. Parents or caregivers may be able to assist. i. Able to calm and reassure child ii. Often well versed on their child’s medical conditions iii. Oxygen or nebulizer administration 3. Communication and documentation a. Communicate and document all relevant information to ED personnel.

Respiratory Emergencies and Management (1 of 5)
Respiratory problems are the leading cause of cardiopulmonary arrest in the pediatric population. Failure to recognize and treat will lead to death. Patient must work harder to breathe and will eventually go into respiratory failure if left untreated. In the early stages, you may note changes in behavior, such as combativeness, restlessness, and anxiety. Lecture Outline VI. Respiratory Emergencies and Management A. Respiratory emergencies 1. Respiratory problems are the leading cause of cardiopulmonary arrest in the pediatric population. a. Failure to recognize and treat declining respiratory status will lead to death. b. During respiratory distress, the pediatric patient is working harder to breathe and will eventually go into respiratory failure if left untreated. 2. In the early stages of respiratory distress, you may note changes in the pediatric patient’s behavior, such as combativeness, restlessness, and anxiety.

Signs and symptoms of increased work of breathing: Nasal flaring Abnormal breath sounds Accessory muscle use Tripod position Lecture Outline 3. Signs and symptoms of increased work of breathing: a. Nasal flaring b. Abnormal breath sounds c. Accessory muscle use d. The tripod position

As the pediatric patient progresses to possible respiratory failure: Efforts to breathe decrease. Chest rises less with inspiration. Body has used up all available energy stores and cannot continue to support extra work of breathing. Without care, cyanosis may develop. Lecture Outline 4. As the pediatric patient progresses to possible respiratory failure: a. Efforts to breathe decrease. b. The chest rises less with inspiration. c. The body has used up all its available energy stores and cannot continue to support the extra work of breathing. i. Without care, cyanosis may develop.

As the patient progresses to possible respiratory failure (cont’d): Changes in behavior and eventually, altered level of consciousness Patient may experience periods of apnea. Heart muscle becomes hypoxic. Leads to bradycardia If heart rate is slow, you must begin CPR. Lecture Outline d. Changes in behavior will also occur until the pediatric patient demonstrates an altered level of consciousness. e. Patient may also experience periods of apnea. f. As the lack of oxygen becomes more serious, the heart muscle becomes hypoxic and slows down. i. Leads to bradycardia. (a) Almost always an ominous sign in pediatric patients. ii. If the heart rate is slow, you must begin CPR immediately. (a) May quickly progress to cardiopulmonary arrest.

As the patient progresses to possible respiratory failure (cont’d): Respiratory failure does not always indicate airway obstruction. Condition can progress from respiratory distress to failure at any time; reassess frequently. A child or infant needs supplemental oxygen. For infants and children in possible respiratory failure, assist ventilation with a BVM and 100% oxygen. Allow patient to remain in a comfortable position. Lecture Outline g. Respiratory failure does not always indicate airway obstruction. i. It may indicate trauma, nervous system problems, dehydration, or metabolic disturbances. h. A pediatric patient’s condition can progress from respiratory distress to respiratory failure at any time. i. You must reassess the pediatric patient frequently. i. A child or infant in respiratory distress needs supplemental oxygen. j. For infants and children in possible respiratory failure, assist ventilation with a BVM and 100% oxygen. k. Allow the pediatric patient to remain in a comfortable position, usually on the lap of the caregiver or parent.

Airway Obstruction (1 of 10)
Children can obstruct airway with any object they can fit into their mouth. In cases of trauma, teeth may have been dislodged into the airway. Lecture Outline B. Airway obstruction 1. Children can obstruct their airway with any object they can fit into their mouth. 2. In cases of trauma, teeth may have been dislodged into the airway. © Jones & Bartlett Learning. Photographed by Kimberly Potvin.

Blood, vomitus, or other secretions can cause severe airway obstruction. Infections can cause obstruction. Infection should be considered if patient has congestion, fever, drooling, and cold symptoms. Croup is an infection in the airway below the level of the vocal cords. Epiglottitis is an infection of the soft tissue above the level of the vocal cords. Lecture Outline 3. Blood, vomitus, or other secretions can also cause mild or severe airway obstruction. 4. Infections, including pneumonia, croup, epiglottitis, and bacterial tracheitis, can also cause airway obstructions. a. Infection should be considered if patient has congestion, fever, drooling, and cold symptoms. b. Croup is an infection in the airway below the level of the vocal cords. c. Epiglottitis is an infection of the soft tissue in the area above the vocal cords.

This figure shows the effects of epiglottitis. Epiglottitis is an infection that can cause airway obstruction in pediatric patients. © Jones & Bartlett Learning.

Obstruction by foreign object may involve upper or lower airway. Obstruction may be partial or complete. Signs and symptoms associated with partial upper airway obstruction include decreased breath sounds and stridor. Infants or children with a complete airway obstruction will not make any sound, have no breath sounds, and become rapidly cyanotic Signs and symptoms of lower airway obstruction include wheezing and/or crackles. Lecture Outline 5. Obstruction by a foreign object may involve the upper or lower airway. a. Obstruction may be partial or complete. b. Signs and symptoms frequently associated with a partial upper airway obstruction include decreased or absent breath sounds and stridor. i. Stridor is usually caused by swelling of the area surrounding the vocal cords or upper airway obstruction. ii. Infants or children with a complete airway obstruction will not make any sounds, will have no breath sounds, and will become rapidly cyanotic. c. Signs and symptoms of a lower airway obstruction include wheezing and/or crackles.

Best way to auscultate breath sounds in pediatric patient is to listen to both sides of the chest at armpit level. Lecture Outline 6. The best way to auscultate breath sounds in a pediatric patient is to listen on both sides of the chest at the level of the armpit.

Immediately begin treatment of airway obstruction. Encourage coughing to clear airway when patient is conscious and forcibly coughing. If this does not remove the object, do not intervene except to provide oxygen. Allow patient to remain in whatever position is most comfortable. Lecture Outline 7. Immediately begin treatment of a pediatric patient with an airway obstruction. a. If the patient is conscious and coughing forcefully and someone saw him or her ingest a foreign object, encourage the child to cough to clear the airway. i. If this does not remove the object, do not intervene, except to provide supplemental oxygen. ii. Allow the patient to remain in whatever position is most comfortable, and monitor his or her condition.

If you see signs of a severe airway obstruction, attempt to clear the airway immediately. Ineffective cough (no sound) Inability to speak or cry Increasing respiratory difficulty, with stridor Cyanosis Loss of consciousness Lecture Outline b. If you see signs of a severe airway obstruction, attempt to clear the airway immediately: i. Ineffective cough (no sound) ii. Inability to speak or cry iii. Increasing respiratory difficulty, with stridor iv. Cyanosis v. Loss of consciousness

If an infant is conscious with a complete airway obstruction, perform up to five back blows followed by chest thrusts. Position the infant facedown on your forearm, and slap the back forcefully five times. If the airway does not clear, flip the child onto his or her back and perform up to five chest thrusts in the same manner you would for CPR. Repeat the process until the obstruction clears, or until the infant becomes unconscious. Lecture Outline c. If an infant is conscious with a complete airway obstruction, perform up to five back blows followed by chest thrusts. i. Position the infant facedown on your forearm, supporting the jaw and head with your hand, and slap the back forcefully five times with the heel of your other hand. ii. If the airway does not clear, flip the child onto his or her back and perform up to five chest thrusts in the same manner you would for CPR. iii. Repeat the process until the obstruction clears, or until the infant becomes unconscious.

If a child is conscious with a complete airway obstruction, perform abdominal thrusts (Heimlich maneuver). Continue until the obstruction is relieved or until the child loses consciousness. Lecture Outline d. If a child is conscious with a complete airway obstruction, perform abdominal thrusts (Heimlich maneuver). i. Continue until the obstruction is relieved or until the child loses consciousness.

Use head tilt–chin lift and finger sweep to remove a visible foreign body in an unconscious pediatric patient. Use chest compressions to relieve a severe airway obstruction in an unconscious pediatric patient. Increases pressure in chest, creating an artificial cough Lecture Outline e. Use head tilt–chin lift and finger sweep to remove a visible foreign body in an unconscious pediatric patient. f. Chest compressions are recommended to relieve a severe airway obstruction in an unconscious pediatric patient. i. Increases pressure in chest, creating an artificial cough that may force a foreign body from the airway.

Asthma (1 of 4) A condition in which the bronchioles become inflamed, swell, and produce excessive mucus, leading to difficulty breathing. A true emergency if not promptly identified and treated 10% of US children are affected. Common causes for asthma attack include upper respiratory infection, exercise, exposure to cold air or smoke, and emotional stress. Lecture Outline C. Asthma 1. A condition in which the smaller air passages (bronchioles) become inflamed, swell, and produce excessive mucus, which leads to difficulty breathing. 2. A true emergency if not promptly identified and treated a. According to the Centers for Disease Control and Prevention (CDC), 10% of children in the United States have asthma and, in 2007 alone, 185 children died of asthma. b. Common causes for an asthma attack include upper respiratory infection, exercise, exposure to cold air or smoke, and emotional stress.

Asthma (2 of 4) Signs and symptoms: Wheezing as patient exhales
In some cases, airway is completely blocked and no air movement is heard. Cyanosis and respiratory arrest may quickly develop. Tripod position allows for easier breathing. Lecture Outline 3. Signs and symptoms of asthma a. Characteristic wheezing as patients attempt to exhale through partially obstructed lower air passages b. In other cases, the airways are completely blocked and no air movement is heard. c. Cyanosis and respiratory arrest may quickly develop. d. Tripod position allows for easier breathing.

Asthma (3 of 4) Treatment Allow patient to assume a position of comfort. Administer supplemental oxygen. Bronchodilator via metered-dose inhaler with a spacer mask device (if protocol allows) If assisting ventilations, use slow, gentle breaths. Resist temptation to squeeze bag hard and fast. Lecture Outline 4. Treatment of pediatric patient with asthma a. If possible, let the pediatric patient assume a position of comfort in a parent’s lap. b. Administer supplemental oxygen via route that is tolerated by the child. c. A bronchodilator via a metered-dose inhaler with a spacer mask device may be administered based on local protocols. i. Often the parents or caregivers have attempted multiple dosages of albuterol. (a) In this case, meet ALS providers en route for advanced care. d. If you must assist ventilations, use slow, gentle breaths. i. Resist the temptation to squeeze the reservoir bag hard and fast.

Asthma (4 of 4) Treatment (cont’d)
A prolonged asthma attack may progress into status asthmaticus. A true emergency Administer oxygen and provide rapid transport. If patient becomes exhausted and stops struggling to breathe: Manage airway aggressively, administer oxygen, and transport promptly. Consider ALS support. Lecture Outline e. A prolonged, unrelieved asthma attack may progress into status asthmaticus. i. A true emergency ii. Administer oxygen and provide rapid transport to the ED. f. If patient becomes so exhausted he or she stops struggling to breathe, the patient is not recovering and is likely to stop breathing. i. Manage airway aggressively, administer oxygen, and transport promptly. ii. ALS support should be considered.

Pneumonia (1 of 3) Leading cause of death in children
Pneumonia is a general term that refers to an infection to the lungs. Often a secondary infection Can also occur from chemical ingestion Diseases causing immunodeficiency in children increase risk. Incidence is greatest during fall and winter months Lecture Outline D. Pneumonia 1. According to the World Health Organization, pneumonia is the leading cause of death for over 2 million children worldwide annually. 2. Pneumonia is a general term that refers to an infection of the lungs. a. Often a secondary infection; it occurs after a preexisting infection such as a cold. b. Can also occur from chemical ingestion or a direct lung injury or a submersion incident c. Children with diseases causing immunodeficiency are at increased risk for developing pneumonia. d. Incidence is greatest during fall and winter months.

Pneumonia (2 of 3) Presentation in pediatric patient:
Unusual rapid breathing Sometimes with grunting or wheezing sounds Nasal flaring Tachypnea Hypothermia or fever Unilateral diminished breath sounds or crackles over the infected lung segments Lecture Outline 3. Presentation in the pediatric patient a. Unusual rapid breathing, or will breathe with grunting or wheezing sounds b. Nasal flaring c. Tachypnea d. Hypothermia or fever e. Unilateral diminished breath sounds or crackles over the infected lung segments

Pneumonia (3 of 3) Pediatric patient treatment:
Primary treatment will be supportive. Monitor airway and breathing status. Administer supplemental oxygen if required. If the child is wheezing, administer a bronchodilator, if permitted. Diagnosis of pneumonia must be confirmed in the hospital. Lecture Outline 4. Treatment of pneumonia in the pediatric patient a. Primary treatment will be supportive. b. Monitor the patient’s airway and breathing status. c. Administer supplemental oxygen if required. d. If the child is wheezing, administer a bronchodilator if permitted in your EMS system. 5. Diagnosis of pneumonia must be confirmed in the hospital.

Croup (1 of 2) An infection of the airway below the level of the vocal cords, usually caused by a virus. Typically seen in children between ages 6 months and 3 years Easily passed between children The disease starts with a cold, cough, and a low-grade fever that develops over 2 days. The hallmark signs of croup are stridor and a seal-bark cough. Lecture Outline E. Croup 1. Croup (laryngotracheobronchitis) is an infection of the airway below the level of the vocal cords, usually caused by a virus. a. Typically seen in children between ages 6 months and 3 years b. Easily passed between children 2. The disease starts with a cold, cough, and a low-grade fever that develops over 2 days. a. The hallmark signs of croup are stridor and a seal-bark cough.

Croup (2 of 2) Treatment Croup often responds well to the administration of humidified oxygen. Bronchodilators are not indicated for croup and can make the child worse. Lecture Outline 3. Croup often responds well to the administration of humidified oxygen. a. Bronchodilators are not indicated for croup and can make the child worse.

Epiglottitis Bacterial infection of the soft tissue in the area above the vocal cords Incidence decreased since development of vaccine Epiglottis can swell to two to three times normal size. Children look ill, report a very sore throat, and have a high fever. Tripod position and drooling Lecture Outline F. Epiglottitis 1. Epiglottitis (supraglottitis) is an infection of the soft tissue in the area above the vocal cords. a. Bacterial infection is the most common cause. 2. Since the development of a vaccine against one organism that causes epiglottitis, the incidence of this disease has dramatically decreased. 3. In preschool- and school-aged children especially, the epiglottis can swell to two to three times its normal size. 4. Children with this infection look ill, report a very sore throat, and have a high fever. a. They will often be found in the tripod position and drooling.

Bronchiolitis (1 of 3) Specific viral illness of newborns and toddlers, often caused by RSV. Causes inflammation of the bronchioles RSV is highly contagious and spread through coughing or sneezing. Virus can survive on surfaces. Virus tends to spread rapidly through schools and in childcare centers. Lecture Outline G. Bronchiolitis 1. Specific viral illness of newborns and toddlers, often caused by respiratory syncytial virus (RSV). a. Causes inflammation of the bronchioles. b. RSV is highly contagious and spread through coughing or sneezing. c. Virus can survive on surfaces. d. Virus tends to spread rapidly through schools and childcare centers.

Bronchiolitis (2 of 3) More common in premature infants and results in copious secretion Occurs during first 2 years of life; more common in males Most widespread in winter and early spring Bronchioles become inflamed, swell, and fill with mucus. Airways can easily become blocked. Look for signs of dehydration, shortness of breath, and fever. Lecture Outline 2. More common in premature infants and results in copious secretion that may require suctioning a. Occurs during the first 2 years of life and is more common in males b. Most widespread in winter and early spring c. Bronchioles become inflamed, swell, and fill with mucus. d. Airways of infants and young children can easily become blocked. 3. Look for signs of dehydration, shortness of breath, and fever.

Bronchiolitis (3 of 3) Treatment Humidified oxygen is helpful.
Use calm demeanor when approaching. Allow patient to remain in position of comfort. Treat airway and breathing problems. Humidified oxygen is helpful. Consider ALS backup. Lecture Outline 4. Treatment of bronchiolitis in the pediatric patient a. Display a calm demeanor when approaching. b. Allow patient to remain in position of comfort. c. Treat airway and breathing problems as appropriate. d. Humidified oxygen is helpful if available. e. Consider ALS backup.

Pertussis (1 of 2) Pertussis (whooping cough) is caused by a bacterium spread via respiratory droplets. Less common in the United States Signs and symptoms: coughing, sneezing, and a runny nose Coughing becomes more severe with distinctive whoop sound during inspiration. Infants may develop pneumonia or respiratory failure. Lecture Outline H. Pertussis 1. Pertussis, also known as whooping cough, is a communicable disease caused by a bacterium that is spread through respiratory droplets. 2. As the result of vaccinations, this potentially deadly disease is less common in the United States. 3. The typical signs and symptoms are similar to a common cold: coughing, sneezing, and a runny nose. a. As the disease progresses, the coughing becomes more severe and is characterized by the distinctive whoop sound heard during inspiration. b. Infants infected with pertussis may develop pneumonia or respiratory failure.

Pertussis (2 of 2) To treat pediatric patients, keep the airway patent (open) and transport. Pertussis is contagious, so follow standard precautions, including wearing a mask and eye protection. Lecture Outline 4. To treat pediatric patients, keep the airway patent (open) and transport. 5. Pertussis is contagious, so follow standard precautions, including wearing a mask and eye protection.

Airway Adjuncts (1 of 4) Devices that help to maintain the airway or assist in providing artificial ventilation, including: Oropharyngeal and nasopharyngeal airways Bite blocks BVMs Lecture Outline I. Airway adjuncts 1. Devices that help to maintain the airway or assist in providing artificial ventilation, including: a. Oropharyngeal and nasopharyngeal airways b. Bite blocks c. BVMs

Airway Adjuncts (2 of 4) Oropharyngeal airway
Keeps tongue from blocking airway and makes suctioning easier Should be used for pediatric patients who are unconscious and in respiratory failure Should not be used in conscious patients or those who have a gag reflex or who may have ingested a caustic or petroleum-based product Lecture Outline 2. Oropharyngeal airway a. Designed to keep the tongue from blocking the airway and makes suctioning easier b. Should be used for pediatric patients who are unconscious and in possible respiratory failure i. Should not be used in conscious patients, those who have a gag reflex, or who may have ingested a caustic or petroleum-based product c. See Skill Drill 34-2.

Airway Adjuncts (3 of 4) Nasopharyngeal airway Usually well tolerated.
Used for responsive pediatric patients. Used in association with possible respiratory failure Rarely used in infants younger than 1 year Should not be used if there is nasal obstruction or head trauma Lecture Outline 3. Nasopharyngeal airway. a. Usually well tolerated and not as likely to cause vomiting b. Used for responsive pediatric patients c. Used in association with possible respiratory failure d. Rarely used in infants younger than 1 year e. Should not be used in pediatric patients with nasal obstruction or head trauma f. See Skill Drill 34-3.

Airway Adjuncts (4 of 4) Nasopharyngeal airway potential problems:
May become obstructed by mucus, blood, vomitus, or the soft tissues of the pharynx May stimulate the vagus nerve and slow the heart rate, or enter the esophagus, causing gastric distention May cause a spasm of the larynx and result in vomiting if inserted into responsive patient Should not be used when pediatric patients have facial trauma because the airway may tear soft tissues and cause bleeding into the airway Lecture Outline g. Potential problems: i. An airway with a small diameter may easily become obstructed by mucus, blood, vomitus, or the soft tissues of the pharynx. ii. If the airway is too long, it may stimulate the vagus nerve and slow the heart rate, or enter the esophagus, causing gastric distention. iii. May cause a spasm of the larynx and result in vomiting if inserted into responsive patient. iv. Nasopharyngeal airways should not be used when pediatric patients have facial trauma because the airway may tear soft tissues and cause bleeding into the airway.

Oxygen Delivery Devices (1 of 9)
Several options for pediatric patient Blow-by technique at 6 L/min provides more than 21% oxygen concentration. Nasal cannula at 1 to 6 L/min provides 24% to 44% oxygen concentration. Nonrebreathing mask at 10 to 15 L/min provides up to 95% oxygen concentration. BVM at 10 to 15 L/min provides nearly 100% oxygen concentration. Lecture Outline J. Oxygen delivery devices 1. In treating infants and children who require more than the usual 21% oxygen found in room air, you have several options. a. Blow-by technique at 6 L/min provides more than 21% oxygen concentration. b. Nasal cannula at 1 to 6 L/min provides 24% to 44% oxygen concentration. c. Nonrebreathing mask at 10 to 15 L/min provides up to 95% oxygen concentration. d. BVM (with oxygen reservoir) at 10 to 15 L/min provides nearly 100% oxygen concentration.

Nonrebreathing mask, nasal cannula, or simple face mask is indicated for pediatric patients who have adequate respirations and/or tidal volumes. BVM is used for those with respirations less than 12 breaths/min or more than 60 breaths/min, an altered LOC, or inadequate tidal volume. Lecture Outline 2. Use of a nonrebreathing mask, a nasal cannula, or a simple face mask is indicated only for pediatric patients who have adequate respirations and/or tidal volumes. a. Children with respirations of fewer than 12 breaths/min or more than 60 breaths/min, and altered level of consciousness, and/or an inadequate tidal volume, should receive assisted ventilations with a BVM.

Blow-by method Less effective than face mask or nasal cannula for oxygen delivery. Does not provide high oxygen concentration. Administration: Place tubing through hole in bottom of cup. Connect tube to oxygen source at 6 L/min. Hold cup 1 to 2 inches away from nose and mouth. Lecture Outline 3. Blow-by method a. The blow-by method is not nearly as effective as a face mask or nasal cannula for delivering oxygen. b. Does not provide high concentration of oxygen, but it is better than no oxygen. c. Administering blow-by oxygen: i. Place oxygen tubing through a small hole in the bottom of an 8-oz cup. ii. Connect tubing to an oxygen source set at 6 L/min. iii. Hold the cup approximately 1 to 2 inches away from the child’s nose and mouth.

Nasal cannula Some patients prefer the nasal cannula; some find it uncomfortable. Applying a nasal cannula: Choose appropriately sized nasal cannula. Connect tubing to an oxygen source at 1 to 6 L/min. Lecture Outline 4. Nasal cannula a. Some pediatric patients prefer the nasal cannula; others find it uncomfortable. b. Applying a nasal cannula: i. Choose the appropriately sized pediatric nasal cannula. The prongs should not fill the nares entirely. ii. Connect the tubing to an oxygen source set at 1 to 6 L/min.

Nonrebreathing mask Delivers up to 90% oxygen Allows patient to exhale all carbon dioxide without rebreathing it Applying a nonrebreathing mask: Select appropriately sized mask. Connect tubing to oxygen source at 10 to 15 L/min. Adjust oxygen flow as needed. Lecture Outline 5. Nonrebreathing mask a. Delivers up to 90% oxygen to the pediatric patient and allows them to exhale all carbon dioxide without rebreathing it b. Applying a nonrebreathing mask: i. Select the appropriately sized pediatric nonrebreathing mask. The mask should extend from the bridge of the nose to the cleft of the chin. ii. Connect the tubing to an oxygen source set at 10 to 15 L/min. iii. Adjust oxygen flow as needed to match the respiratory rate and depth.

Bag-valve mask Indicated in patients with too fast or too slow respirations, who are unresponsive, or who do not respond to painful stimuli Assisting ventilations with BVM: Select appropriately sized equipment. Maintain a good seal with the mask on the face. Ventilate at the appropriate rate and volume, using a slow, gentle squeeze. Lecture Outline 6. Bag-valve mask a. Indicated for pediatric patients who have respirations that are either too slow or too fast, who are unresponsive, or who do not respond in a purposeful way to painful stimuli b. Assisting ventilation using a BVM: i. Ensure that you have the appropriate equipment in the right size. Mask should extend from the bridge of the nose to the cleft of the chin. ii. Maintain a good seal with the mask on the face. iii. Ventilate at the appropriate rate and volume using a slow, gentle squeeze. Stop squeezing and begin to release the bag as soon as the chest wall begins to rise, indicating that the lungs are filled to capacity. 7. One-person BVM ventilation on a pediatric patient a. See Skill Drill to perform one-person BVM ventilation.

Two-person BVM ventilation Similar to one-person BVM ventilation except one rescuer holds the mask to the face and maintains the head position Usually more effective in maintaining a tight seal Lecture Outline 8. Two-person BVM ventilation on a pediatric patient a. This procedure is similar to one-person BVM ventilation except that one rescuer holds the mask to the patient’s face and maintains the head position and the other ventilates. b. Usually more effective in maintaining a tight seal, as it provides an open airway due to proper body position

Cardiopulmonary Arrest
Cardiac arrest in pediatric patients is associated with respiratory failure and arrest. Children are affected differently by decreasing oxygen concentration. Adults become hypoxic and the heart develops a dysrhythmia that leads to sudden cardiac death. Children become hypoxic and their hearts slow down, becoming more bradycardic. Lecture Outline K. Cardiopulmonary arrest 1. Cardiac arrest in infants and children is most often associated with respiratory failure and arrest. a. Children are affected differently than adults when it comes to decreasing oxygen concentration. i. Adults become hypoxic and the heart develops a dysrhythmia that leads to sudden cardiac death. (a) This is often in the form of ventricular fibrillation. (b) AED is the treatment of choice. ii. Children become hypoxic and their hearts slow down, becoming more bradycardic. (a) The heart will beat slower and more weakly until no pulse is felt. (b) The overall survival rate from cardiac arrest in the prehospital setting is about 8%. (c) Prehospital survival rate from respiratory arrest is over 70%. (d) A child who is breathing very poorly with a slowing heart rate must be ventilated with high concentrations of oxygen early to try to oxygenate the heart before cardiac arrest occurs.

Shock (1 of 11) A condition that develops when the circulatory system is unable to deliver a sufficient amount of blood to the organs Results in organ failure and eventually cardiopulmonary arrest Compensated shock is the early stage of shock. Decompensated shock is the later stage of shock. Lecture Outline VII. Circulation Emergencies and Management A. Shock 1. Shock is a condition that develops when the circulatory system is unable to deliver a sufficient amount of blood to the organs of the body. a. Results in organ failure and eventually cardiopulmonary arrest i. Compensated shock is the early stage of shock, when the body can still compensate for the blood loss. ii. Decompensated shock is the later stage of shock, when the blood pressure is falling.

Shock (2 of 11) Common causes include: Trauma injury with blood loss
Especially abdominal Dehydration from diarrhea or vomiting Severe infection Neurologic injury Such as severe head trauma Lecture Outline 2. In pediatric patients, the most common causes of shock include: a. Traumatic injury with blood loss i. Especially abdominal b. Dehydration from diarrhea or vomiting c. Severe infection d. Neurologic injury i. Such as severe head trauma

Shock (3 of 11) Common causes include (cont’d):
Severe allergic reaction/anaphylaxis to an allergen Insect bite or food allergy Diseases of the heart Collapsed lung Tension pneumothorax Blood or fluid around the heart Cardiac tamponade Pericarditis Lecture Outline e. A severe allergic reaction/anaphylaxis to an allergen i. Insect bite or food allergy f. Diseases of the heart g. A collapsed lung i. Tension pneumothorax h. Blood or fluid around the heart i. Cardiac tamponade ii. Pericarditis

Shock (4 of 11) Pediatric patients respond differently than adults to fluid loss. May respond by increasing heart rate, increasing respirations, and showing signs of pale or blue skin Lecture Outline 3. Pediatric patients respond differently than adults to fluid loss. a. They may respond by increasing their heart rate, increasing respirations, and showing signs of pale or blue skin.

Shock (5 of 11) Signs of shock in children
Tachycardia Poor capillary refill time (> 2 seconds) Mental status changes Treat shock by assessing ABCs, intervening as required. The order becomes CAB if there is obvious life-threatening external hemorrhage or if cardiac arrest is suspected. Pediatric patients do not demonstrate a fall in blood pressure until shock is severe. Lecture Outline 4. Signs of shock in children are as follows: a. Tachycardia b. Poor capillary refill time (>2 seconds) c. Mental status changes 5. Begin treating shock by assessing the ABCs, intervening as required. a. If there is an obvious life-threatening external hemorrhage, the order becomes CAB, because bleeding control is the most critical step. b. If cardiac arrest is suspected, the order also becomes CAB because chest compressions are essential. c. Pediatric patients in shock often have increased respirations but do not demonstrate a fall in blood pressure until shock is severe.

Shock (6 of 11) Treatment In assessing circulation, assess the rate and quality of pulses; the temperature and moisture of hands and feet; skin color; and capillary refill time, with 2 seconds being normal. Changes in pulse rate, color, skin signs, and capillary refill time suggest shock. Blood pressure is the most difficult vital sign to measure. Assessment should also include talking with the parents or caregivers. Lecture Outline d. In assessing circulation, pay attention to the following: i. Pulse (a) Assess rate and quality of pulses. A weak, “thready” pulse is a sign of a problem. Anything over 160 beats/min suggests shock. ii. Skin signs (a) Assess temperature and moisture of hands and feet. iii. Capillary refill time (a) A 2-second capillary refill time is normal. iv. Color (a) Assess skin color. v. Changes (a) Changes in pulse rate, color, skin signs, and capillary refill time are all important clues suggesting shock. vi. Blood pressure is the most difficult vital sign to measure in pediatric patients. (a) Blood pressure may be normal with compensated shock. (b) Low blood pressure is a sign of decompensated shock requiring ALS and rapid transport. vii. Assessment should also include talking with the parents or caregivers to determine when signs and symptoms first appeared and whether any of the following occurred: (a) Decreased urine output (b) Absence of tears (c) Sunken fontanelle (d) Changes in level of consciousness and behavior

Shock (7 of 11) Treatment (cont’d)
Limit your management to simple interventions. Do not waste time performing field procedures. Ensure airway is open; prepare for artificial ventilation. Control bleeding. Lecture Outline e. Limit your management to these simple interventions. f. Do not waste time performing field procedures. g. Ensure the airway is open and prepare for artificial ventilation. h. Control bleeding.

Shock (8 of 11) Treatment (cont’d)
Give supplemental oxygen by mask or blow-by. Continue to monitor airway and breathing. Position the pediatric patient in a position of comfort. Keep warm with blankets and heat. Provide immediate transport. Contact ALS backup as needed. Lecture Outline i. Give supplemental oxygen by mask or blow-by method. j. Continue to monitor airway and breathing. k. Position the pediatric patient in a position of comfort. l. Keep the patient warm with blankets and by turning up the heat in the patient compartment. m. Provide immediate transport. n. Contact ALS backup as needed.

Shock (9 of 11) Anaphylaxis
A life-threatening allergic reaction that involves generalized, multisystem response Characterized by airway swelling and dilation of blood vessels Common causes are insect sting, medications, or food allergy. Lecture Outline 6. Anaphylaxis a. Anaphylaxis, also called anaphylactic shock, is a life-threatening allergic reaction that involves a generalized, multisystem response to an antigen. i. Characterized by airway swelling and dilation of blood vessels ii. Common causes are an insect stings, medications, or food.

Shock (10 of 11) Anaphylaxis (cont’d) Signs and symptoms Hypoperfusion
Stridor and/or wheezing Increased work of breathing Altered appearance Restlessness, agitation, and sometimes a sense of impending doom Hives Lecture Outline b. Signs and symptoms of anaphylactic shock in the pediatric patient: i. Hypoperfusion ii. Stridor and/or wheezing iii. Increased work of breathing iv. Altered appearance v. Restlessness, agitation, and sometimes a sense of impending doom vi. Hives are usually present.

Shock (11 of 11) Anaphylaxis (cont’d) Treatment
Maintain airway and administer oxygen. Allow caregiver to assist in positioning the patient, oxygen delivery, and maintaining calm. Assist with epinephrine auto-injector based on protocol. Provide rapid transport. Lecture Outline c. Treatment of pediatric patient with anaphylactic shock: i. Maintain the airway and administer oxygen via a tolerated route. ii. In stable patients, allow the parent or caregiver to assist in the positioning of the patient, oxygen delivery, and keeping the patient calm. iii. Based on protocol, assist with epinephrine auto-injector, if available. (a) Pediatric epinephrine auto-injector is supplied in a dose of 0.15 mg and is given in intramuscularly in the lateral thigh. iv. Provide rapid transport.

Bleeding Disorders Hemophilia is a congenital condition in which patients lack normal clotting factors. Most forms are hereditary and severe. Predominantly found in male population Bleeding may occur spontaneously. All injuries become serious because blood does not clot. Lecture Outline B. Bleeding disorders 1. Hemophilia is a congenital condition in which the patient lacks one or more of the normal clotting factors of blood. a. Most forms are hereditary and are severe. b. Predominantly found in male population. c. Bleeding may occur spontaneously. d. All injuries become serious because blood does not clot. i. Transport immediately. ii. Do not delay to apply a tourniquet for life-threatening hemorrhage.

Altered Mental Status (1 of 2)
Abnormal neurologic state Understanding developmental changes and listening to caregiver’s opinion are key. AEIOU-TIPPS reflects major causes of AMS. Lecture Outline VIII. Neurologic Emergencies and Management A. Altered mental status (AMS) 1. AMS is an abnormal neurologic state in which the pediatric patient is less alert and interactive than is age appropriate. a. Understanding normal developmental or age-related changes in behavior and listening carefully to the caregiver’s opinion are key. b. A pediatric patient not behaving in a developmentally appropriate manner could indicate an altered mental status. c. The mnemonic AEIOU-TIPPS reflects the major causes of AMS. © Jones & Bartlett Learning.

Altered Mental Status (2 of 2)
Signs and symptoms vary from simple confusion to coma. Management focuses on ABCs and transport. If level of consciousness is low, patient may not be able to protect airway. Ensure patent airway and adequate breathing through nonrebreathing mask or BVM. Transport to the hospital. Lecture Outline d. Signs and symptoms vary from simple confusion to coma. e. Management focuses on the ABCs and transport. i. If level of consciousness is low, the pediatric patient may not be able to protect his or her airway. (a) Ensure a patent airway and adequate breathing through a nonrebreathing mask or a BVM. ii. Transport to the hospital.

Seizures (1 of 6) Result of disorganized electrical activity in the brain Manifests in a variety of ways Subtle in infants, with an abnormal gaze, sucking, and/or “bicycling” motions More obvious in older children with repetitive muscle contractions and unresponsiveness Lecture Outline B. Seizures 1. A seizure is the result of disorganized electrical activity in the brain. a. Common causes of seizures: i. Child abuse ii. Electrolyte imbalance iii. Fever iv. Hypoglycemia v. Infection vi. Ingestion vii. Lack of oxygen viii. Medications ix. Poisoning x. Seizure disorder xi. Recreational drug use xii. Head trauma xiii. No cause can be found b. May manifest in a variety of ways, depending on the age of the child. c. Seizures in infants can be very subtle, consisting only of an abnormal gaze, sucking motions, or “bicycling” motions.

Seizures (2 of 6) Common causes of seizures Lecture Outline
d. In older children, seizures are more obvious and typically consist of repetitive muscle contractions and unresponsiveness. © Jones & Bartlett Learning.

Seizures (3 of 6) Once seizure stops and muscles relax, it is referred to as postical state. The longer and more intense the seizures are, the longer it will take for this imbalance to correct itself. Postictal state is over once normal level of consciousness is regained. Lecture Outline i. Once a seizure stops, the patient’s muscles relax, becoming almost flaccid or floppy, and the breath becomes labored. (a) This is the postictal state. ii. The longer and more intense the seizures are, the longer it will take for this imbalance to correct itself. (a) Once the pediatric patient regains a normal level of consciousness, the postictal state is over.

Seizures (4 of 6) Status epilepticus
Seizures that continue every few minutes without regaining consciousness in between or last longer than 30 minutes Recurring or prolonged seizures should be considered life threatening. If patient does not regain consciousness or continues to seize, protect him or her from harming self and call for ALS backup. Lecture Outline e. Seizures that continue every few minutes without regaining consciousness in between or last longer than 30 minutes are referred to as status epilepticus. f. Recurring or prolonged seizures should be considered potentially life threatening. i. If the patient does not regain consciousness or continues to seize, protect the patient from harming himself or herself and call for ALS backup. (a) These patients need advanced airway management and medication to stop the seizure.

Seizures (5 of 6) Management
Securing and protecting airway are priority. Position head to open airway. Clear mouth with suction. Use recovery position if patient is vomiting. Provide 100% oxygen by nonrebreathing mask or blow-by method Begin BVM ventilations if no signs of improvement. Lecture Outline 2. Management a. Securing and protecting the airway are your priorities. i. Position the head to open the airway. ii. Clear the mouth with suction. iii. Consider placing the pediatric patient in the recovery position if he or she is vomiting and suction is inadequate. b. Provide 100% oxygen by nonrebreathing mask or blow-by method. i. Begin BVM ventilations if there are no signs of improvement.

Seizures (6 of 6) Management (cont’d)
Some caregivers will have given the child a rectal dose of diazepam (Diastat) prior to your arrival; monitor breathing and level of consciousness carefully. Transport to the appropriate facility Lecture Outline ii. Some caregivers will have given the child a rectal dose of diazepam (Diastat) prior to your arrival; monitor breathing and level of consciousness carefully. iii. Transport to the appropriate facility.

Meningitis (1 of 7) Inflammation of tissue that covers the spinal cord and brain Caused by infection by bacteria, viruses, fungi, or parasites Left untreated, can lead to brain damage or death Being able to recognize a pediatric patient with meningitis is an important skill to have. Lecture Outline C. Meningitis 1. Inflammation of tissue (meninges) that covers the spinal cord and brain. a. Caused by an infection by bacteria, viruses, fungi, or parasites. b. If left untreated, it can lead to brain damage or death. 2. Being able to recognize a pediatric patient with meningitis is an important skill to have.

Meningitis (2 of 7) Individuals at greater risk: Males Newborn infants
Compromised immune system by AIDS or cancer History of brain, spinal cord, back surgery Children who have had head trauma Children with shunts, pins, or other foreign bodies in their brain or spinal cord Especially children with VP shunts Lecture Outline a. Some individuals are at greater risk: i. Males ii. Newborn infants iii. Children with compromised immune systems from AIDS or cancer iv. Children who have any history of brain, spinal cord, or back surgery v. Children who have had head trauma vi. Children with shunts, pins, or other foreign bodies within their brain or spinal cord (a) Especially children with ventriculoperitoneal (VP) shunts

Meningitis (3 of 7) Signs and symptoms vary with age.
Fever and altered level of consciousness Changes can range from mild headache to inability to interact appropriately. Child may experience seizure. Infants younger than 2 to 3 months can have apnea, cyanosis, fever, distinct high-pitched cry, or hypothermia. Lecture Outline 3. Signs and symptoms of meningitis vary, depending on age of the patient. a. Fever and altered level of consciousness are common symptoms in all ages. i. Changes in the level of consciousness can range from a mild or severe headache to confusion, lethargy, and/or an inability to understand commands or interact appropriately. b. Child may also experience a seizure, which may be the first sign of meningitis. c. Infants younger than 2 to 3 months can have apnea, cyanosis, fever, a distinct high-pitched cry, or hypothermia.

Meningitis (4 of 7) Signs and symptoms (cont’d)
“Meningeal irritation” or “meningeal signs” are terms to describe pain that accompanies movement. Often results in characteristic stiff neck In an infant, increasing irritability and a bulging fontanelle without crying Lecture Outline d. “Menigeal irritation” or “meningeal signs” are terms used by doctors to describe the pain that accompanies movement. i. Often results in characteristic stiff neck. e. One sign of meningitis in an infant is increasing irritability and a bulging fontanelle without crying.

Meningitis (5 of 7) Neisseria meningitidis is a bacterium that causes rapid onset of meningitis symptoms. Often leads to shock and death Children present with small, pinpoint, cherry-red spots or a larger purple/black rash. Serious risk of sepsis, shock, and death Lecture Outline 4. Neisseria meningitidis is a bacterium that causes a rapid onset of meningitis symptoms, often leading to shock and death. a. Children with N. meningitidis typically have small, pinpoint, cherry-red spots or a larger purple/black rash on the face or body. i. These children are at serious risk of sepsis, shock, and death.

Meningitis (6 of 7) The figure on this slide shows Neisseria meningitidis. Children with Neisseria meningitidis typically have small, pinpoint, cherry-red spots or a larger purple/black rash. © Mediscan/Visuals Unlimited.

Meningitis (7 of 7) Patients with suspected meningitis should be considered contagious. Use standard precautions. Follow up to learn the patient’s diagnosis. Treatment Provide supplemental oxygen and assist with ventilations if needed. Reassess vital signs frequently. Lecture Outline 5. All pediatric patients with suspected meningitis should be considered contagious. a. Follow standard precautions when dealing with pediatric patients with possible meningitis and follow up to learn the patient’s diagnosis. b. If exposed to saliva or respiratory secretions, you should receive antibiotics. 6. Treatment of child with suspected meningitis: a. Provide with supplemental oxygen and assist with ventilations if needed. b. Reassess vital signs frequently during transport to highest level of service available.

Gastrointestinal Emergencies and Management (1 of 3)
Never take a complaint of abdominal pain lightly. Monitor for signs and symptoms of shock. Complaints of gastrointestinal origin are common in pediatric patients. Ingestion of certain foods or unknown substance In most cases, patient will be experiencing abdominal discomfort with nausea, vomiting, and diarrhea. Can cause dehydration Lecture Outline IX. Gastrointestinal Emergencies and Management A. Never take a complaint of abdominal pain lightly, because a large amount of bleeding may occur within the abdominal cavity without any outward signs of shock. 1. Monitor for signs and symptoms of shock, including an altered mental status; pale, cool skin; tachypnea; tachycardia; and bradycardia. B. Complaints of gastrointestinal origin are common in pediatric patients. 1. May be from ingestion of certain foods or unknown substances 2. In most cases, the pediatric patient will be experiencing abdominal discomfort with nausea, vomiting, and/or diarrhea. a. Vomiting and diarrhea can cause dehydration.

Appendicitis is also common. If untreated, can lead to peritonitis or shock Will typically present with fever and pain upon palpation of right lower quadrant Rebound tenderness is a common sign. If you suspect appendicitis, promptly transport to the hospital for evaluation. Lecture Outline 3. Appendicitis is also common. a. If untreated, can lead to peritonitis or shock i. Peritonitis is inflammation of the peritoneum, which lines the abdominal cavity. b. Will typically present with a fever and pain on palpation of the right lower abdominal quadrant. c. Rebound tenderness is a common sign associated with appendicitis. 4. If you suspect appendicitis, promptly transport to the hospital for further evaluation.

Obtain a thorough history from the primary caregiver. How many wet diapers today? Is the child tolerating liquids and keeping them down? How many times has the child had diarrhea and for how long? Are tears present during crying? Lecture Outline 5. Obtain a thorough history from the primary caregiver. In particular, ask questions such as: a. How many wet diapers has the child had today? b. Is your child tolerating liquids, and is he or she able to keep them down? c. How many times has your child had diarrhea and for how long? d. When he or she cries, are tears present?

Poisoning Emergencies and Management (1 of 5)
Common among children Can occur by ingesting, inhaling, injecting, or absorbing toxic substances Common sources: Alcohol Aspirin and acetaminophen Cosmetics Household cleaning products Houseplants Lecture Outline X. Poisoning Emergencies and Management A. Poisoning is common among children. 1. Can occur by ingesting, inhaling, injecting, or absorbing a toxic substance 2. Common sources of poisoning in children are: a. Alcohol b. Aspirin and acetaminophen c. Cosmetics d. Household cleaning products such as bleach and furniture polish e. Houseplants

Common sources (cont’d): Iron Prescription medications of family members Illicit (street) drugs Vitamins Signs and symptoms vary, depending on substance, age, and weight. May appear normal, confused, sleepy, or unconscious. Some substances only take one pill to be lethal Lecture Outline f. Iron g. Prescription medications h. Illicit (street) drugs i. Vitamins 3. Signs and symptoms of poisoning vary widely, depending on the substance and the age and weight of the child. a. The patient may appear normal at first, or may be confused, sleepy, or unconscious. b. Some substances only take one pill to be lethal in a small child.

Be alert for signs of abuse. After primary assessment, ask caregiver the following: What is the substance involved? Approximately how much was ingested? What time did the incident occur? Any changes in behavior or level of consciousness? Any choking or coughing after the exposure? Lecture Outline 4. Be alert for signs of abuse. 5. After you have completed your primary assessment, ask the parent or caregiver the following questions: a. What is the substance(s) involved? b. Approximately how much of the substance was ingested or involved in the exposure? c. What time did the incident occur? d. Are there any changes in behavior or level of consciousness? e. Was there any choking or coughing after the exposure?

Contact Poison Control for assistance. Treatment Perform external decontamination. Remove tablets or fragments from mouth. Wash or brush poison from skin. Assess and maintain ABCs and monitor breathing. If shock is present, treat and transport. Give activated charcoal according to medical control or local protocol. Lecture Outline 6. Contact Poison Control for assistance in identifying poisons. 7. Treatment of a poisoned pediatric patient: a. First perform an external decontamination. i. Remove tablets or fragments from the patient’s mouth. ii. Wash or brush poison from the skin. b. Assess and maintain ABCs and monitor breathing. i. Provide oxygen and perform ventilations if necessary. c. If child demonstrates signs of shock, position supine, keep the child warm, and transport promptly. d. In some cases, give activated charcoal, according to medical control or local protocol.

Activated charcoal Not recommended for those who have ingested acid, an alkali, or a petroleum product Not recommended for patients who have decreased level of consciousness Common trade names are Insta-Char, Actidose, and Liqui-Char. Usual dose is 1 g per kilogram of body weight; pediatric dose is 12.5 to 25 g. Lecture Outline i. Not indicated for pediatric patients who have ingested an acid, an alkali, or a petroleum product. ii. Not recommended for pediatric patients who have a decreased level of consciousness and cannot protect their own airway, or who are unable to swallow. iii. Some common trade names for the suspension form are Insta-Char, Actidose, and Liqui-Char. iv. The usual dose for a child is 1 g of activated charcoal per kilogram of body weight; pediatric dose is 12.5 to 25 g.

Dehydration Emergencies and Management (1 of 3)
Occurs when fluid loss is greater than fluid intake Vomiting and diarrhea are common causes. Can lead to shock and death if left untreated Infants and children are at greater risk. Life-threatening dehydration can overcome an infant in a matter of hours. Can be mild, moderate, or severe Lecture Outline XI. Dehydration Emergencies and Management A. Dehydration occurs when fluid losses are greater than fluid intake. 1. Vomiting and diarrhea are the most common causes of dehydration. a. If left untreated, dehydration can lead to shock and death. 2. Infants and children are at greater risk than adults for dehydration because their fluid reserves are smaller than those in adults. a. Life-threatening dehydration can overcome an infant in a matter of hours. 3. Dehydration can be mild, moderate, or severe.

Mild dehydration signs Dry lips and gums, decreased saliva and wet diapers Moderate dehydration signs Sunken eyes, sleepiness, irritability, loose skin, sunken fontanelles Severe dehydration signs Mottled, cool, clammy skin; delayed CRT; increased respiration Lecture Outline 4. Signs of mild dehydration: a. Dry lips and gums b. Decreased saliva c. Few wet diapers 5. Signs of moderate dehydration: a. Sunken eyes b. Sleepiness c. Irritability d. Loose skin e. Sunken fontanelles 6. Signs of severe dehydration: a. Mottled, cool, clammy skin b. Delayed capillary response time c. Increased respirations

Treatment Assess ABCs and obtain baseline vital signs. If severe, ALS backup may be necessary for IV access. Transport to ED. Lecture Outline B. Treating dehydration in the pediatric patient: 1. Assess ABCs, obtain baseline vital signs. a. If dehydration is severe, ALS backup may be necessary for IV access. 2. Transport to the ED if signs are moderate to severe. Courtesy of Ronald Dieckmann, M.D.

Fever Emergencies and Management (1 of 4)
An increase in body temperature 100.4°F (38°C) or higher is abnormal. Rarely life threatening Causes Infection Status epilepticus Cancer Drug ingestion (aspirin) Lecture Outline XII. Fever Emergencies and Management A. Simply defined, a fever is an increase in body temperature, usually in response to an infection. 1. Temperatures of 100.4°F (38°C) or higher are considered abnormal. 2. Fever is rarely life threatening, but fever with a rash can be the sign of a serious condition, such as meningitis. 3. Common causes of fever in pediatric patients include: a. Infection b. Status epilepticus c. Cancer d. Drug ingestion (aspirin)

Causes (cont’d) Arthritis Systemic lupus erythematosus (rash on nose) High environmental temperature Result of internal body mechanism in which heat generation is increased and heat loss is decreased Lecture Outline e. Arthritis f. Systemic lupus erythematosus (rash across nose) g. High environmental temperature 4. Fever is the result of an internal body mechanism in which heat generation is increased and heat loss is decreased.

Accurate body temperature is important for pediatric patients. Rectal temperature is most accurate for infants and toddlers. Under tongue or arm will work for older children. Lecture Outline 5. An accurate body temperature is an important vital sign for pediatric patients. a. A rectal temperature is the most accurate for infants to toddlers. b. Older children will be able to follow directions for placing a thermometer under the tongue or arm.

Patient may present with signs of respiratory distress, shock, a stiff neck, a rash, hot skin, flushed cheeks, and, in infants, bulging fontanelles. Assess for nausea, vomiting, diarrhea, decreased feedings, and headache. Transport and manage ABCs. Follow standard precautions with communicable diseases. Lecture Outline 6. Depending on the source of infection, the pediatric patient may present with signs of respiratory distress; shock; a stiff neck; a rash; skin that is hot to the touch; flushed cheeks; seizures; and, in infants, bulging fontanelles. a. Assess the patient for other signs and symptoms such as nausea, vomiting, diarrhea, decreased feedings, and headache. 7. Provide rapid transport and manage the patient’s ABCs. a. Follow standard precautions if you suspect the patient may have a communicable disease.

Febrile Seizures (1 of 2) Common between 6 months and 6 years
Caused by fever alone Typically occur on first day of febrile illness Characterized by tonic-clonic activity Last less than 15 minutes with little or no postictal state May be sign of more serious problem Lecture Outline B. Febrile seizures. 1. Febrile seizures are common in children between the ages of 6 months and 6 years. a. Most pediatric seizures are the result of fever alone, which is why they are called febrile seizures. b. Typically occur on the first day of a febrile illness c. Characterized by generalized tonic-clonic seizure activity d. Last fewer than 15 minutes with little or no postictal state e. May be a sign of a more serious problem, such as meningitis

Febrile Seizures (2 of 2) Assess ABCs, provide cooling measures with tepid water, and provide prompt transport. All patients with febrile seizures need to be seen in the hospital setting. Lecture Outline 2. Assess ABCs, provide cooling measures with tepid water, and provide prompt transport. a. All patients with febrile seizures need to be seen in the hospital setting.

Drowning Emergencies and Management (1 of 3)
Take steps to ensure your own safety. Second-most-common cause of unintentional death among children Children younger than age 5 are most at risk. Alcohol frequently a factor with adolescents. Principal condition is lack of oxygen. A few minutes without oxygen affects the heart, lungs, and brain. Hypothermia from submersion in icy water Diving increases risk of neck and spinal cord injuries. Lecture Outline XIII. Drowning Emergencies and Management A. In drowning emergencies, you must always take steps to ensure your own safety. 1. Drowning is the second-most-common cause of unintentional death among children aged 1 to 4 years in the United States. a. Children often fall into swimming pools and lakes, but many drown in bathtubs and even puddles or buckets of water. b. Older adolescents drown when swimming or boating; alcohol is frequently a factor. 2. Principal condition that results from drowning is lack of oxygen. a. Even a few minutes without oxygen affects the heart, lungs, and brain. i. Causes life-threatening problems such as cardiac arrest, respiratory failure, and coma b. Submersion in icy water can lead to hypothermia. i. Most people in this situation die. c. Diving into water increases the risk of neck and spinal cord injuries.

Signs and symptoms Coughing and choking Airway obstruction and difficulty breathing AMS and seizure activity Unresponsiveness Fast, slow, or no pulse Pale, cyanotic skin Abdominal distention Lecture Outline 3. Signs and symptoms will vary based on type and length of submersion. a. A pediatric patient may present with coughing; choking; airway obstruction; difficulty breathing; AMS; seizure activity; unresponsiveness; fast, slow, or no pulse; pale, cyanotic skin; and abdominal distention.

Assess and manage ABCs. Contact ALS crew to intervene if needed. Administer 100% oxygen. Apply cervical collar if trauma is suspected. Perform CPR in unresponsive patient in cardiopulmonary arrest. Lecture Outline B. Management of drowning emergencies 1. Assess and manage ABCs. 2. Contact ALS crew to intervene if needed. 3. Administer 100% oxygen via nonrebreathing mask or BVM if assisted ventilations are required. a. Be prepared to suction as these patients often vomit. 4. If trauma is suspected, apply a cervical collar and place the patient on a long board. a. Pad all open spaces under the pediatric patient before securing the patient onto the board. 5. Perform CPR on unresponsive patient in cardiopulmonary arrest.

Pediatric Trauma Emergencies and Management
Number one killer of children in the US Quality of care can impact recovery. The muscles and bones of children continue to grow well into adolescence. Fracture of the femur is rare. Source of major blood loss Older children and adolescents are prone to long bone fractures. Lecture Outline XIV. Pediatric Trauma Emergencies and Management A. Unintentional injuries are the number one killer of children in the United States. 1. Quality of care in the first few minutes after a child has been injured can have an enormous impact on that child’s chances for complete recovery. 2. The muscles and bones of children continue to grow well into adolescence. a. For this reason, coupled with their risk-taking approach to activities, adolescents are prone to fractures of the extremities. 3. A fracture of the femur is rare in pediatric patients, but when it does occur, it is a source of major blood loss. 4. Older children and adolescents are prone to long bone fractures (femur and humerus) because they tend to take more risks during physical activities.

Physical Differences Children are smaller than adults.
Locations of injuries may be different. Children’s bones and soft tissues are less well developed than an adult’s. Force of injury affects structures differently. A child’s head is proportionally larger than an adult’s and exerts greater stress on the neck structures during a deceleration injury. Lecture Outline B. Physical differences 1. Children are smaller than adults, and therefore the location of their injuries may differ from that of an adult’s for the same type of crash. 2. Children’s bones and soft tissues are less well developed than those of an adult’s, and therefore the force of an injury affects these structures differently. a. Because a child’s head is proportionally larger than an adult’s, it exerts greater stress on the neck structures during a deceleration injury.

Psychological Differences
Psychologic differences Often injured because of underdeveloped judgment and lack of experience Always assume the child has serious head and neck injuries. Lecture Outline C. Psychologic differences 1. Children are often injured because of their underdeveloped judgment and their lack of experience. 2. Always assume the child has serious head and neck injuries.

Injury Patterns (1 of 2) Important for EMT to understand physical and psychologic characteristics of children Vehicle collisions Children can dart out in front of motor vehicles without looking. Typically sustain high-energy injuries to the head, spine, abdomen, pelvis, or legs. Lecture Outline D. Injury patterns 1. It is important for the EMT to understand the special physical and psychologic characteristics of children and what makes them more likely to have certain kinds of injuries. 2. Vehicle collisions a. Children playing or riding a bicycle can dart out in front of motor vehicles without looking. i. The area of greatest injury varies, depending on the size of the child and the height of the bumper at the time of impact. b. Children involved in these types of injuries typically sustain high-energy injuries to the head, spine, abdomen, pelvis, or legs.

Injury Patterns (2 of 2) Sport injuries
Children are often injured in organized sports activities. Head and neck injuries can occur in contact sports such as football, wrestling, ice hockey, field hockey, soccer, or lacrosse. Remember to immoblilze cervical spine. Be familiar with protocols for helmet removal. Lecture Outline 3. Sport activities a. Children, especially those who are older or adolescents, are often injured in organized sports activities. b. Head and neck injuries can occur after high-speed collisions in contact sports such as football, wrestling, ice hockey, field hockey, soccer, or lacrosse. c. Remember to immobilize the cervical spine when caring for children with sport-related injuries. i. Be familiar with your local protocols for helmet removal.

Injuries to Specific Body Systems (1 of 14)
Head injuries Common in children because the size of the head in relation to the body Infant has softer, thinner skull. May result in brain injury Scalp and facial vessels may cause great deal of blood loss if not controlled. Lecture Outline E. Injuries to specific body systems 1. Head injuries a. Head injuries are common in children because the size of a child’s head in relation to the body is larger than that of an adult. b. An infant also has a softer, thinner skull, which may result in injury to the brain tissues. c. The scalp and facial vessels can bleed very easily and may cause a great deal of blood loss if not controlled.

Head injuries (cont’d) Nausea and vomiting are common signs and symptoms of a head injury in children. Easy to mistake for abdominal injury or illness Should suspect a serious head injury in any child who experiences nausea and vomiting after a traumatic event Lecture Outline d. Nausea and vomiting are common signs and symptoms of a head injury in children. i. Easy to mistake for abdominal injury or illness ii. You should suspect a serious head injury in any child who experiences nausea and vomiting after a traumatic event.

Immobilization Necessary for all children with possible head or spinal injuries after a traumatic event Immobilization can be difficult because of the child’s body proportions. Younger children require padding under the torso to maintain a neutral position. May be necessary to immobilize child in a car seat Lecture Outline e. Immobilization i. Spinal immobilization is necessary for all children who have possible head or spinal injuries after a traumatic event. ii. See Skill Drill 34-5. iii. Immobilization can be difficult because of the child’s body proportions. (a) Young children require padding under the torso to maintain a neutral position. iv. See Skill Drill 34-6 for steps to immobilize a pediatric patient in a car seat.

Immobilization (cont’d) Around 8 to 10 years of age, children no longer require padding under the torso and can lie supine on the backboard. Padding will be required along the sides to properly secure the child on an adult-sized backboard. Lecture Outline (b) At around 8 to 10 years of age, children no longer require padding underneath the torso. They can lie supine on the backboard. (c) Padding will be required along the sides so the child can be properly secured on an adult-sized backboard.

Chest injuries Usually the result of blunt trauma Chest wall flexibility in children can produce a flail chest. May be injuries within the chest even though there may be no sign of external injury Pediatric patients are managed in the same way as adults. Lecture Outline 2. Chest injuries a. Usually the result of blunt rather than penetrating trauma b. Chest wall flexibility in children can produce a flail chest. i. Keep this in mind as you assess a child who has sustained high-energy blunt trauma to the chest. ii. Even though there may be no external sign of injury, there may be injuries within the chest. iii. Pediatric patients are managed in the same manner as adults.

Abdominal injuries Common in children Children can compensate for blood loss better than adults. Children can have a serious injury without early external evidence of a problem. Monitor all children for signs of shock. If signs of shock are evident, prevent hypothermia with blankets. Lecture Outline 3. Abdominal injuries a. Abdominal injuries are common in children. i. Children can compensate for significant blood loss better than adults without signs or symptoms of shock developing. ii. Children can have a serious injury without early external evidence of a problem. b. All children with abdominal injuries should be monitored for signs and symptoms of shock, including a weak, rapid pulse; cold, clammy skim; decreased capillary refill; confusion; and decreased systolic blood pressure. c. If the patient shows signs and symptoms of shock, prevent hypothermia by keeping the patient warm with blankets. i. If the patient has bradycardia, ventilate. d. Monitor during transport.

The figure on this slide illustrates the impact of blood loss on the potential for developing shock. All children with abdominal injuries should be monitored closely for signs and symptoms of shock. © Jones & Bartlett Learning.

Burns Burns to children are considered more serious than burns to adults. Have more surface area to relative total body mass, which means greater fluid and heat loss Do not tolerate burns as well as adults More likely to go into shock, develop hypothermia, and experience airway problems Lecture Outline 4. Burns a. Burns to children are generally considered more serious than burns to adults. i. Infants and children have more surface area relative to total body mass, which means greater fluid and heat loss. ii. Children also do not tolerate burns as well as adults do. iii. Children are also more likely to go into shock, develop hypothermia, and experience airway problems.

Burns (cont’d) Common ways that children are burned: Exposure to hot substances Hot items on a stove Exposure to caustic substances Infection is a common problem. Burned skin cannot resist infection as effectively. Sterile techniques should be used when handling skin. Lecture Outline b. The most common ways in which children are burned are: i. Exposure to hot substances, such as scalding water in the bathtub ii. Hot items on a stove iii. Exposure to caustic substances such as cleaning solvents or paint thinners iv. Older children are more likely to be burned by flames from fire. (a) You should expect possible internal injuries when you see a child with burns around the mouth and face. c. Infection is a common problem following a burn injury in a child. i. Burned skin cannot resist infection as effectively as normal skin can. ii. Sterile techniques should be used in handling the skin of children with burn wounds if possible.

Burns (cont’d) Should consider child abuse in any burn situation Report any information about suspicions. Severity Minor Moderate Critical Lecture Outline d. You should consider the possibility of child abuse in any burn situation. i. Make sure you report any information about suspicions to the appropriate authorities. e. Severity of burns: i. Minor: Partial-thickness burns involving less than 10% of body surface. ii. Moderate: Partial-thickness burns involving 10% to 20% of body surface. iii. Severe: Any full-thickness burn; a partial-thickness burn involving more than 20% of body surface; or any burn involving the hands, feet, face, airway, or genitalia.

Burns (cont’d) Pediatric patients are managed in the same manner as adults. Prevent hypothermia if shock is suspected. If patient shows bradycardia, ventilate. Monitor the patient during transport. Lecture Outline f. Pediatric patients are managed in the same manner as adults. i. If the patient shows signs and symptoms of shock, prevent hypothermia by keeping him or her warm with blankets. ii. If the patient has bradycardia, ventilate. iii. Monitor the patient during transport.

Injuries to the extremities Children have immature bones with active growth centers. Growth of long bones occurs from the ends at specialized growth plates. Potential weak spots Incomplete or greenstick fractures can occur. Lecture Outline 5. Injuries of the extremities a. Children have immature bones with active growth centers. b. Growth of long bones occurs from the ends at specialized growth plates. i. Growth plates are potential weak spots. ii. Incomplete or greenstick fractures can occur.

Injuries to the extremities (cont’d) Generally, extremity injuries in children are managed in the same manner as adults. Painful deformed limbs with evidence of broken bones should be splinted. Should not attempt to use adult immobilization devices on pediatric patient Lecture Outline c. Generally, extremity injuries in children are managed in the same manner as those in adults. i. Painful deformed limbs with evidence of broken bones should be splinted. (a) Specialized splinting equipment should only be used if it fits the pediatric patient. (b) You should not attempt to use adult immobilization devices on a pediatric patient unless the pediatric patient is large enough to properly fit.

Pain management First step is recognizing the patient is in pain. Look for visual clues and use the Wong-Baker FACES pain scale. Interventions are limited to positioning, ice packs, and extremity elevation. Will decrease pain and swelling to injury site ALS interventions may be needed. Another important tool is kindness and providing emotional support. Lecture Outline 6. Pain management a. The first step in pain management is recognizing that the patient is in pain. b. Since some pediatric patients will be nonverbal or have a limited vocabulary, look for visual clues and use the Wong-Baker FACES pain scale. c. You are limited to the following pain interventions: i. Positioning ii. Ice packs iii. Extremity elevation d. These interventions will decrease the pain and swelling to the injury site. i. Additional ALS interventions may be needed. e. Another important tool is kindness and providing emotional support.

Disaster Management (1 of 4)
JumpSTART triage system Intended for patients younger than age 8 years and weighing less than 100 lb Four triage categories Green Yellow Red Black Lecture Outline XV. Disaster Management A. The JumpSTART triage system was developed for pediatric patients. 1. Intended for patients younger than age 8 years and weighing less than 100 lb. 2. There are four triage categories in the JumpSTART system, designated by colors corresponding to different levels of urgency.

JumpSTART triage system (cont’d) Green: minor; not in need of immediate treatment Able to walk (except in infants) Yellow: delayed treatment Presence of spontaneous breathing, with peripheral pulse, responsive to painful stimuli Lecture Outline 3. Decision points include: a. Able to walk (except in infants) i. Green tag: minor, not in need of immediate treatment b. Presence of spontaneous breathing, with a peripheral pulse, and appropriately responsive to painful stimuli i. Yellow tag: delayed treatment

JumpSTART triage system (cont’d) Red: immediate response Apnea responsive to positioning or rescue breathing; respiratory failure; breathing but without a pulse; or inappropriate painful response Black: deceased or expectant deceased Apneic without pulse, or apneic and unresponsive to rescue breathing Lecture Outline c. Apnea responsive to positioning or rescue breathing, respiratory failure, breathing but without a pulse, or inappropriate painful response. i. Red tag: immediate response d. Apneic and without pulse, or apneic and unresponsive to rescue breathing i. Black tag: considered deceased or expectant deceased

Child Abuse and Neglect
Any improper or excessive action that injures or otherwise harms a child Includes physical abuse, sexual abuse, neglect, and emotional abuse Over half a million children are victims of child abuse annually. Many children suffer life-threatening injuries. If abuse is not reported, it is likely to happen again. Lecture Outline XVI. Child Abuse and Neglect A. Child abuse means any improper or excessive action that injures or otherwise harms a child or infant. 1. Includes physical abuse, sexual abuse, neglect, and emotional abuse 2. Over half a million children are victims of child abuse annually. a. Many of these children suffer life-threatening injuries and some die. b. If suspected child abuse is not reported, the abuse is likely to happen again, perhaps causing permanent injury or even death. i. Must be aware of the signs of child abuse and neglect ii. It is your responsibility to report it to law enforcement or child protection agencies.

Signs of Abuse (1 of 10) You will be called to homes because of reported injury to a child. Child abuse occurs in every socioeconomic status. Be aware of patient’s surroundings. Document findings objectively. Lecture Outline B. Signs of abuse 1. As an EMT you will be called to homes because of reported injury to a child. 2. Child abuse occurs in every socioeconomic status, so you must be aware of the patient’s surroundings and document your findings objectively. a. You may be called to testify in abuse cases; it is essential to record all findings, including any statements made by caregivers or others on the scene.

Signs of Abuse (2 of 10) Ask yourself the following:
Injury typical for age of child? MOI reported consistent with the injury? Caregiver behaving appropriately? Evidence of drinking or drug use at scene? Delay in seeking care for the child? Good relationship between child and caregiver or parent? Lecture Outline 3. Ask yourself the following questions: a. Is the injury typical for the developmental level of the child? b. Is the MOI reported consistent with the injury? c. Is the parent or caregiver behaving appropriately? d. Is there evidence of drinking or drug use at the scene? e. Was there a delay in seeking care for the child? f. Is there a good relationship between the caregiver and the child?

Signs of Abuse (3 of 10) Ask yourself the following (cont’d):
Are there multiple injuries at different stages of healing? Any unusual marks or bruises that may have been caused by cigarettes, grids, or branding injuries? Are there several types of injuries? Any burns on hands or feet that involve a glove distribution? Lecture Outline g. Does the child have multiple injuries at different stages of healing? h. Does the child have any unusual marks or bruises that may have been caused by cigarettes, grids, or branding injuries? i. Does the child have several types of injuries? j. Does the child have any burns on the hands or feet that involve a glove distribution?

Signs of Abuse (4 of 10) Ask yourself the following (cont’d):
Is there unexplained decreased level of consciousness? Is the child clean and an appropriate weight for his or her age? Is there any rectal or vaginal bleeding? What does the home look like? Clean or dirty? Warm or cold? Is there food? Lecture Outline k. Is there an unexplained decreased level of consciousness? l. Is the child clean and an appropriate weight for his or her age? m. Is there any rectal or vaginal bleeding? n. What does the home look like? Clean or dirty? Is it warm or cold? Is there food?

Signs of Abuse (5 of 10) CHILD ABUSE mnemonic may help.
Lecture Outline 4. The mnemonic CHILD ABUSE may help you remember the points to look for. © Jones & Bartlett Learning.

Signs of Abuse (6 of 10) Bruises Observe color and location.
New bruises are pink or red. Over time turn blue, then green, then yellow-brown and faded Bruises to the back, buttocks, or face are suspicious and are usually inflicted by a person. Lecture Outline 5. Bruises a. Observe the color and location of any bruises. i. New bruises are pink or red. ii. Over time, bruises turn blue, then green, then yellow-brown and faded. iii. Note the location of bruises. (a) Bruises to the back, buttocks, or face are suspicious and are usually inflicted by a person.

Signs of Abuse (7 of 10) Burns
Burns to the penis, testicles, vagina, or buttocks are usually inflicted by someone else. Burns that look like a glove are usually inflicted by someone else. You should suspect child abuse if the child has cigarettes burns or grid pattern burns. Lecture Outline 6. Burns a. Burns to the penis, testicles, vagina, or buttocks are usually inflicted by someone else. b. Burns that encircle a hand or foot to look like a glove are usually inflicted by someone else. i. You should suspect abuse if the child has cigarette burns or grid pattern burns.

Signs of Abuse (8 of 10) Fractures
Fractures of the humerus or femur do not normally occur without major trauma. Falls from bed are not usually associated with fractures. Maintain an index of suspicion if an infant or young child sustains a femur fracture. A complete fracture of the bone indicates that the child was exposed to a great deal of traumatic force. Lecture Outline 7. Fractures a. Fractures of the humerus or femur do not normally occur without major trauma. b. Falls from a bed are not usually associated with fractures. i. You should maintain some index of suspicion if an infant or young child sustains a femur fracture. ii. A complete fracture of the bone in a pediatric patient indicates that the child was exposed to a great deal of traumatic force.

Signs of Abuse (9 of 10) Shaken baby syndrome
Infants may sustain life-threatening head trauma by being shaken or struck. Bleeding within the head and damage to the cervical spine Infant will be found unconscious, often without evidence of external trauma. Lecture Outline 8. Shaken baby syndrome a. Infants may sustain life-threatening head trauma by being shaken or struck in the head. i. This life-threatening condition is called shaken baby syndrome. ii. There is bleeding within the head and damage to the cervical spine as a result of intentional, forceful shaking. iii. The infant will be found unconscious, often without evidence of external trauma. (a) Infant may appear to be in cardiopulmonary arrest.

Signs of Abuse (10 of 10) Shaken baby syndrome (cont’d) Neglect
Shaking tears blood vessels in the brain, resulting in bleeding around the brain. Pressure from blood results in an increase in cranial pressure leading to coma and/or death. Neglect Refusal or failure to provide life necessities Examples are water, clothing, shelter, personal hygiene, medicine, comfort, personal safety Lecture Outline b. Shaking tears blood vessels in the brain, resulting in bleeding around the brain. i. The pressure from the blood results in an increased cranial pressure, leading to coma and/or death. 9. Neglect a. Neglect is refusal or failure on the part of the caregiver to provide life necessities. i. Examples are water, clothing, shelter, personal hygiene, medicine, comfort, and personal safety. b. Children who are neglected are often dirty, too thin, or appear developmentally delayed because of lack of stimulation. i. You may observe such children when you are making calls for unrelated problems. ii. Report all suspected cases of neglect.

Symptoms and Other Indicators of Abuse (1 of 2)
Abused children may appear withdrawn, fearful, or hostile. Should be concerned if child does not want to discuss how an injury occurred Parent may reveal a history of “accidents.” Be alert for conflicting stories or lack of concern. Abuser may be a parent, caregiver, relative, or friend of the family. Lecture Outline C. Symptoms and other indicators of abuse 1. Abused children may appear withdrawn, fearful, or hostile. a. You should be concerned if a child does not want to discuss how an injury occurred. 2. Occasionally, the parent or caregiver will reveal a history of “accidents.” a. Be alert for conflicting stories or a lack of concern from the caregiver. b. The abuser may be a parent, caregiver, relative, or friend of the family.

Symptoms and Other Indicators of Abuse (2 of 2)
EMTs in all states must report suspected abuse. Most states have special forms to do so. Supervisors are generally forbidden to interfere with the reporting. Law enforcement and child protection services will determine whether there is abuse. It is not your job. Lecture Outline 3. EMTs in all states must report suspected abuse. a. Most states have special forms to do so. b. Supervisors are generally forbidden to interfere with the reporting of suspected abuse. c. Law enforcement and child protection services will determine whether there is abuse. i. It is not your job to prove that there is abuse.

Sexual Abuse (1 of 3) Children of any age and gender can be victims of sexual abuse. Maintain an index of suspicion. Often longstanding abuse by relatives Assessment Limited to determining type of dressing required Treat bruises and fractures as well. Do not examine genitalia unless there is evidence of bleeding or other injury. Lecture Outline D. Sexual abuse 1. Children of any age and of either gender can be victims of sexual abuse. a. Maintain an index of suspicion regardless of the patient’s social or economic situation. i. This type of abuse is often the result of longstanding abuse by relatives. 2. Assessment a. Should be limited to determining the type of dressing any injuries require. b. Treat any bruises or fractures as well. c. Do not examine the genitalia of a young child unless there is evidence of bleeding or there is any injury that must be treated.

Sexual Abuse (2 of 3) Assessment (cont’d)
Do not allow child to wash, urinate, or defecate until a physician completes examination. Difficult but important step to preserve evidence Ensure an EMT or police officer of the same gender remains with the child. Maintain professional composure. Assume a caring, concerned approach. Shield the child from onlookers. Lecture Outline d. Do not allow the child to wash, urinate, or defecate before a physician completes a physical examination. i. Difficult step, but important to preserve evidence e. Ensure that an EMT or police officer of the same gender remains with the child, unless locating one will delay transport. f. Maintain professional composure the entire time. i. Assume a concerned, caring approach. ii. Shield the child from onlookers and curious bystanders.

Sexual Abuse (3 of 3) Assessment (cont’d)
Obtain as much information as possible from the child and any witnesses. Transport all children who are victims of sexual assault. Sexual abuse is a crime. Cooperate with law enforcement officials in their investigations. Lecture Outline g. Obtain as much information as possible from the child and any witnesses. i. Child may be hysterical or unwilling to say anything. ii. You are in the best position to obtain the most accurate firsthand information. (a) Record any information carefully and completely on the patient care report. h. Transport all children who are victims of sexual assault. i. Sexual abuse is a crime. i. Cooperate with law enforcement officials in their investigations.

Sudden Infant Death Syndrome (1 of 2)
Unexplained death after complete autopsy About 3,500 infants die of SIDS annually. Baby should be placed on his or her back on a firm mattress, in a crib free of bumpers, blankets, and toys. Baby should sleep in the same room, but not the same bed, chair, or sofa as an adult. Impossible to predict Lecture Outline XVII. Sudden Infant Death Syndrome A. The death of an infant or a young child is called sudden infant death syndrome (SIDS) when, after a complete autopsy, the death remains unexplained. 1. About 3,500 infants die of SIDS annually. a. The American Academy of Pediatrics recommends that a baby be placed on his or her back on a firm mattress, in a crib that is free of bumpers, blankets, and toys. b. The CDC recommends having the baby sleep in the same room, but not the same bed, chair, or sofa, as an adult.

Sudden Infant Death Syndrome (2 of 2)
Risk factors Mother younger than age 20 years Mother smoked during pregnancy Low birth weight Can occur at any time of day You are faced with three tasks Assessment of the scene Assessment and management of patient Communication and support of the family Lecture Outline 2. Although it is impossible to predict SIDS, risk factors include: a. Mother younger than age 20 years b. Mother smoked during pregnancy c. Low birth weight 3. Death as the result of SIDS can occur at any time of day. 4. You will face with three tasks: a. Assessment of the scene b. Assessment and management of the patient c. Communication and support of the family

Patient Assessment and Management (1 of 4)
Victim of SIDS will be pale or blue, not breathing, and unresponsive. Other causes include: Overwhelming infection Child abuse Airway obstruction Meningitis Lecture Outline B. Patient assessment and management 1. An infant who has been a victim of SIDS will be pale or blue, not breathing, and unresponsive. 2. Other causes for such a condition include the following: a. Overwhelming infection b. Child abuse c. Airway obstruction from a foreign object or as a result of infection d. Meningitis

Other causes include (cont’d) Accidental or intentional poisoning Hypoglycemia Congenital metabolic defects Begin with ABC assessment. Provide necessary interventions. Lecture Outline e. Accidental or intentional poisoning f. Hypoglycemia (low blood glucose level) g. Congenital metabolic defects 3. Begin with assessment of the ABCs. a. Provide interventions as necessary.

Depending on how much time has passed, patient may show postmortem changes. Rigor mortis Dependent lividity If you see these signs, call medical control. If no signs of postmortem changes, begin CPR immediately. Lecture Outline b. Depending on how much time has passed, patient may show signs of postmortem changes, including: i. Stiffening of the body, called rigor mortis. ii. Dependent lividity, which is pooling of the blood in the lower parts of the body or those that are in contact with the floor or bed. c. If child shows these signs, call medical control. i. In some EMS systems, a victim of SIDS may be declared dead on the scene. ii. Deciding whether to start CPR on a child with rigor mortis or dependent lividity can be very difficult. (a) Family members may consider anything less to be withholding critical care. iii. Best solution may be to begin CPR and transport child and family to nearest ED. d. If there is no sign of postmortem changes, begin CPR immediately.

As you assess patient, pay special attention to any marks or bruises on the child before performing any procedures. Note any interventions that were performed before your arrival. Lecture Outline 4. As you assess the patient, pay special attention to any marks or bruises on the child before performing any procedures. a. Note any intervention that was done before your arrival.

Scene Assessment Carefully inspect environment, noting condition of scene and where infant was found. Assessment should concentrate on: Signs of illness General condition of the house Signs of poor hygiene Family interaction Site where the infant was discovered Lecture Outline C. Scene assessment 1. Carefully inspect the environment, noting the condition of the scene where the infant was found. 2. Your assessment of the scene should concentrate on the following: a. Signs of illness, including medications, humidifiers, or thermometers b. The general condition of the house c. Signs of poor hygiene d. Family interaction i. Do not allow yourself to be judgmental about family interactions at this time. ii. Do note and report any behavior that is clearly not within the acceptable range, such as physical and verbal abuse. e. The site where the infant was discovered i. Note all items in the infant’s crib or bed, including all pillows, stuffed animals, toys, and small objects.

Communication and Support of the Family
Sudden death of an infant is devastating for a family. Tends to evoke strong emotional responses among health care providers Allow the family to express their grief. Lecture Outline D. Communication and support of the family after the death of a child 1. The sudden death of an infant is a devastating event for a family. a. It also tends to evoke strong emotional responses among health care providers. b. Part of your job at this point is to allow the family to express their grief.

Death of a Child (1 of 5) In addition to medical treatment the child may require, you must provide the family with empathy and understanding. The family may want you to initiate resuscitation efforts, which may or may not conflict with your EMS protocols. Introduce yourself to the child’s parents or caregivers, and ask about the child’s date of birth and medical history. Lecture Outline 2. In addition to any medical treatment the child may require, you must be prepared to offer the family a high level of empathy and understanding. 3. The family may want you to initiate resuscitation efforts, which may or may not conflict with your EMS protocols. 4. Always introduce yourself to the child’s parents or caregivers, and ask about the child’s date of birth and medical history.

Death of a Child (2 of 5) Do not speculate on the cause of the child’s death. The family should be asked whether they want to hold the child and say good-bye. The following interventions are helpful: Use the child’s name. Speak to family members at eye level. Use “died” and “dead” instead of “passed away” or “gone.” Lecture Outline 5. Do not, in any case, speculate on the cause of the child’s death. 6. The family will want to see the child and should be asked whether they want to hold the child and say good-bye. 7. The following interventions are helpful in caring for the family at this time: a. Learn and use the child’s name rather than the impersonal “your child.” b. Speak to family members at eye level, and maintain good eye contact with them. c. Use the word “dead” or “died” when informing the family of the child’s death; euphemisms such as “passed away” or “gone” are ineffective.

Death of a Child (3 of 5) Helpful interventions (cont’d):
Acknowledge family’s feelings, but never say, “I know how you feel.” Offer to call other family members or clergy. Keep any instructions short, simple, and basic. Ask family members if they want to hold the child. Wrap the child in a blanket, and stay with the family while they hold the child. Do not to remove equipment that was used in attempted resuscitation. Lecture Outline d. Acknowledge the family’s feelings (“I know this is devastating for you,”), but never say “I know how you feel,” even if you have experienced a similar event; the statement will anger many people. e. Offer to call other family members or clergy if the family wishes. f. Keep any instructions short, simple, and basic. Emotional distress may limit their ability to process information. g. Ask each adult family member individually whether he or she wants to hold the child. h. Wrap the dead child in a blanket, as you would if he or she were alive, and stay with family members while they hold the child. i. Ask them not to remove tubes or other equipment that was used in an attempted resuscitation.

Death of a Child (4 of 5) Everyone expresses grief in a different way.
Some will require intervention. Many caregivers feel directly responsible for the death of a child. Some EMS systems arrange for home visits after a child’s death for closure. You need training for these visits. Lecture Outline 8. Each individual and each culture expresses grief in a different way. a. Some will require intervention. b. Most caregivers feel directly responsible for the death of a child. i. This does not mean they are actually responsible. ii. Although you should keep the possibility of neglect or abuse in mind, your role is not that of investigator. iii. Further inquiry is the responsibility of law enforcement. 9. Some EMS systems arrange for home visits after a child’s death so that EMS providers and family members can come to some sort of closure. a. You need special training for such visits.

Death of a Child (5 of 5) Child’s death can be very stressful.
Take time before going back to the job. Talk with other EMS colleagues. Be alert for signs of posttraumatic stress in yourself and others. Consider the need for help if signs occur. Lecture Outline 10. A child’s death can be very stressful. a. Take time before going back to the job. b. Talk with other EMS colleagues. c. Be alert for signs of posttraumatic stress in yourself and others. i. Nightmares ii. Restlessness iii. Difficulty sleeping iv. Lack of appetite d. Consider the need for professional help if these signs occur.

Apparent Life-Threatening Event (1 of 2)
Infants who are not breathing, cyanotic, and unresponsive sometimes resume breathing and color with stimulation. Apparent life-threatening event (ALTE) Classic ALTE is characterized by: Distinct change in muscle tone Choking or gagging Lecture Outline E. Apparent life-threatening event 1. Infants who are not breathing and are cyanotic and unresponsive when found sometimes resume breathing and color with stimulation. a. These children have had what is called an apparent life-threatening event (ALTE). i. Called “near-miss SIDS” in the past b. Classic ALTE is characterized by: i. A distinct change in muscle tone ii. Choking or gagging

Apparent Life-Threatening Event (2 of 2)
After ALTE, child may appear healthy and show no signs of illness or distress. Must complete careful assessment and provide rapid transport to the ED. Pay strict attention to airway management. Assess infant’s history and environment. Allow caregivers to ride in the back of the ambulance. Physicians will determine the cause. Lecture Outline c. After the event, the child may appear healthy and show no signs of illness or distress. i. You must complete a careful assessment and provide rapid transport to the ED. d. Pay strict attention to airway management. e. Assess the infant’s history and environment. f. Allow caregivers to ride in the back of the ambulance. g. Physicians will have to determine the cause.

Review How does pediatric anatomy differ from adult anatomy?
The trachea is more rigid. The tongue is proportionately smaller. The epiglottis is less floppy. The head is proportionately larger.

Review Answer: D Rationale: There are several important anatomic differences between pediatric patients and adult patients. The head—specifically the occiput—is proportionately larger. Their tongue and epiglottis are also proportionately larger, and the epiglottis is floppier and more omega-shaped. The child’s airway is narrower at all levels, and the trachea is less rigid and easily collapsible.

Review (1 of 2) How does pediatric anatomy differ from adult anatomy?
The trachea is more rigid. Rationale: A pediatric trachea is less rigid, narrower, and more anterior than an adult trachea. The tongue is proportionately smaller. Rationale: A tongue is proportionally larger than an adult tongue.

Review (2 of 2) How does pediatric anatomy differ from adult anatomy?
The epiglottis is less floppy. Rationale: The epiglottis is floppier and shaped differently. The head is proportionately larger. Rationale: Correct answer

Review When a small child falls from a significant height, the ______ MOST often strikes the ground first. head back feet side

Review Answer: A Rationale: Compared to adults, pediatric patients have proportionately larger heads. When they fall from a significant height, gravity usually takes them headfirst. This is why head trauma is the most common cause of traumatic death in the pediatric patient.

Review (1 of 2) When a small child falls from a significant height, the ______ MOST often strikes the ground first. head Rationale: Correct answer back Rationale: The head is heavier, and gravity tends to tilt the head in a downward direction.

Review (2 of 2) When a small child falls from a significant height, the ______ MOST often strikes the ground first. feet Rationale: Adults will attempt to land feet first. side Rationale: The head is heavier, and gravity tends to tilt the head in a downward direction.

Review When assessing a conscious and alert 9-year-old child, you should: isolate the child from his or her parent. allow the child to answer your questions. obtain all of your information from the parent. avoid placing yourself below the child’s eye level.

Review Answer: B Rationale: A 9-year-old child is capable of answering questions. By allowing a child to answer your questions, you can gain his or her trust and build a good rapport, which facilitates further assessment and treatment. Do not isolate the child from his or her parent, yet do not allow the parent to do all the talking, unless the child is unable to communicate. When assessing any patient, you should place yourself at or slightly below the patient’s eye level. This position is less intimidating and helps to minimize patient anxiety.

Review (1 of 2) When assessing a conscious and alert 9-year-old child, you should: isolate the child from his or her parent. Rationale: Do not isolate a child from his or her parents. allow the child to answer your questions. Rationale: Correct answer

Review (2 of 2) When assessing a conscious and alert 9-year-old child, you should: obtain all of your information from the parent. Rationale: Some information from parents is useful, but allow the child to speak. avoid placing yourself below the child’s eye level. Rationale: Never tower over a child; instead maintain yourself at/or below eye level.

Review The purpose of a shunt is to:
minimize pressure within the skull. reroute blood away from the lungs. instill food directly into the stomach. drain excess fluid from the peritoneum.

Review Answer: A Rationale: A ventriculoperitoneal (VP) shunt—simply called a “shunt”—is a tube that extends from the ventricles (cavities) of the brain to the peritoneal cavity. VP shunts are used to drain excess fluid from the brain, thus preventing increased pressure within the skull.

Review The purpose of a shunt is to:
minimize pressure within the skull. Rationale: Correct answer reroute blood away from the lungs. Rationale: The shunt is connected from the brain to the abdomen. instill food directly into the stomach. Rationale: The shunt drains excess cerebrospinal fluid from the brain. drain excess fluid from the peritoneum. Rationale: The shunt drains excess cerebrospinal fluid from the brain.

Review Which of the following statements regarding febrile seizures is correct? Febrile seizures usually indicate a serious underlying condition, such as meningitis. Most febrile seizures occur in children between the ages of 2 months and 2 years of age. Febrile seizures are rarely associated with tonic-clonic activity, but last for more than 15 minutes. Febrile seizures usually last less than 15 minutes and often do not have a postictal phase.

Review Answer: D Rationale: Febrile seizures are the most common seizures in pediatric patients; they are common between the ages of 6 months and 6 years of age. Most pediatric seizures are due to fever alone—hence the name “febrile” seizure. However, seizures and fever may indicate a more serious underlying condition, such as meningitis. Febrile seizures are characterized by generalized tonic-clonic activity and last less than 15 minutes; if a postictal phase occurs, it is generally very short.

Review (1 of 2) Which of the following statements regarding febrile seizures is correct? Febrile seizures usually indicate a serious underlying condition, such as meningitis. Rationale: Most febrile seizures are caused by fever, but a fever and seizures may be an indication of a serious underlying condition. Most febrile seizures occur between the ages of 2 months and 2 years of age. Rationale: Most febrile seizures occur between the ages of 6 months and 6 years.

Review (2 of 2) Which of the following statements regarding febrile seizures is correct? Febrile seizures are rarely associated with tonic-clonic activity, but last for more than 15 minutes. Rationale: Febrile seizures last less than 15 minutes. Febrile seizures usually last less than 15 minutes and often do not have a postictal phase. Rationale: Correct answer

Review You respond to a sick child late at night. The child appears very ill, has a high fever, and is drooling. He is sitting in a tripod position, struggling to breathe. You should suspect: croup. pneumonia. epiglottitis. severe asthma.

Review Answer: C Rationale: This child has all the classic signs of epiglottitis: high fever, drooling, and severe respiratory distress. Epiglottitis is a potentially life-threatening bacterial infection that causes the epiglottis to swell rapidly and potentially obstruct the airway.

Review (1 of 2) You respond to a sick child late at night. The child appears very ill, has a high fever, and is drooling. He is sitting in a tripod position, struggling to breathe. You should suspect: croup. Rationale: This is a viral disease characterized by edema of the upper airways, a barking cough, and stridor. pneumonia. Rationale: This is an inflammation of the lungs caused by bacteria, viruses, fungi, and other organisms.

Review (2 of 2) You respond to a sick child late at night. The child appears very ill, has a high fever, and is drooling. He is sitting in a tripod position, struggling to breathe. You should suspect: epiglottitis. Rationale: Correct answer severe asthma. Rationale: This is a lower airway condition resulting in intermittent wheezing and excess mucus production.

Review Treatment for a semiconscious child who swallowed an unknown quantity of pills includes: administering 1 g/kg of activated charcoal and rapidly transporting. monitoring the child for vomiting, administering oxygen, and transporting. positioning the child on his left side, elevating his legs 6 inches, and transporting. contacting medical control and requesting permission to induce vomiting.

Review Answer: B Rationale: If a semi- or unconscious child has ingested pills, poisons, or any other type of harmful substance, closely observe for vomiting, give high-flow oxygen (assist ventilations if necessary), and rapidly transport to the emergency department. Do not give activated charcoal to any patient who is not conscious and alert enough to swallow. Induction of vomiting is not indicated for anyone—regardless of age.

Review (1 of 2) Treatment for a semiconscious child who swallowed an unknown quantity of pills includes: administering 1 g/kg of activated charcoal and rapidly transporting. Rationale: Do not give anything by mouth to an individual who is not conscious and alert enough to swallow. monitoring the child for vomiting, administering oxygen, and transporting. Rationale: Correct answer

Review (2 of 2) Treatment for a semiconscious child who swallowed an unknown quantity of pills includes: positioning the child on his left side, elevating his legs 6 inches, and transporting. Rationale: Placing the child in the recovery position is acceptable if vomiting is possible, but the patient’s legs should remain flat. contacting medical control and requesting permission to induce vomiting. Rationale: Inducing vomiting is not indicated for anyone at any age.

Review When using the mnemonic CHILD ABUSE to assess a child for signs of abuse, you should recall that the “D” stands for: delay in seeking care. divorced parents. dirty appearance. disorganized speech.

Review Answer: A Rationale: The mnemonic CHILD ABUSE stands for Consistency of the injury with the child’s developmental age, History inconsistent with the injury, Inappropriate parental concerns, Lack of supervision, Delay in seeking care, Affect, Bruises of varying stages, Unusual injury patterns, Suspicious circumstances, and Environmental clues. A delay in care may happen when the parent or caregiver does not want the abuse noted by other people.

Review (1 of 2) When using the mnemonic CHILD ABUSE to assess a child for signs of abuse, you should recall that the “D” stands for: delay in seeking care. Rationale: Correct answer divorced parents. Rationale: Divorce may put the child at greater risk, but does not indicate the child is being abused.

Review (2 of 2) When using the mnemonic CHILD ABUSE to assess a child for signs of abuse, you should recall that the “D” stands for: dirty appearance. Rationale: This is something providers should be aware of. A potential for abuse exists, but this does not indicate that the child is being abused. disorganized speech. Rationale: This may indicate a learning disability or handicap.

Review (1 of 2) A 4-year-old girl fell from a second-story balcony and landed on her head. She is unresponsive; has slow, irregular breathing; has a large hematoma to the top of her head; and is bleeding from her nose. You should: immediately perform a full-body scan to detect other injuries, administer high-flow oxygen, and transport at once. apply a pediatric-sized cervical collar, administer high-flow oxygen via pediatric nonrebreathing mask, and prepare for immediate transport.

Review (2 of 2) A 4-year-old girl fell from a second-story balcony and landed on her head. She is unresponsive; has slow, irregular breathing; has a large hematoma to the top of her head; and is bleeding from her nose. You should: manually stabilize her head, open her airway with the jaw-thrust maneuver, insert an airway adjunct, and begin assisting her ventilations with a bag-valve mask. suction her airway for up to 10 seconds, insert a nasopharyngeal airway, apply a pediatric-sized cervical collar, and administer oxygen via pediatric nonrebreathing mask.

Review Answer: C Rationale: This child has a severe head injury and is not breathing adequately. You must manually stabilize her head to protect her spine, open her airway with the jaw-thrust maneuver, suction her airway if needed, insert an oropharyngeal airway, and assist her ventilations with a bag-valve mask. The full-body scan is performed after you have performed a primary assessment to detect and correct any life threats. The nasopharyngeal airway is contraindicated for this child; she has a head injury and is bleeding from her nose.

Review (1 of 3) A 4-year-old girl fell from a second-story balcony and landed on her head. She is unresponsive; has slow, irregular breathing; has a large hematoma to the top of her head; and is bleeding from her nose. You should: immediately perform a full-body scan to detect other injuries, administer high-flow oxygen, and transport at once. Rationale: A full-body scan is performed after the primary assessment. apply a pediatric-sized cervical collar, administer high-flow oxygen via pediatric nonrebreathing mask, and prepare for immediate transport. Rationale: Assisted ventilations must be started on a patient with slow, irregular respirations.

Review (2 of 3) A 4-year-old girl fell from a second-story balcony and landed on her head. She is unresponsive; has slow, irregular breathing; has a large hematoma to the top of her head; and is bleeding from her nose. You should: manually stabilize her head, open her airway with the jaw-thrust maneuver, insert an airway adjunct, and begin assisting her ventilations with a bag-valve mask. Rationale: Correct answer

Review (3 of 3) A 4-year-old girl fell from a second-story balcony and landed on her head. She is unresponsive; has slow, irregular breathing; has a large hematoma to the top of her head; and is bleeding from her nose. You should: suction her airway for up to 10 seconds, insert a nasopharyngeal airway, apply a pediatric-sized cervical collar, and administer oxygen via pediatric nonrebreathing mask. Rationale: A nasopharyngeal airway is contraindicated with potential facial injuries. Ventilations need to be maintained with a bag-valve mask.

Review The AVPU scale is used to monitor a patient’s level of consciousness. What does the “P” stand for? Pallor Pediatric Painful Pale

Review Answer: C Rationale: The “P” in the AVPU scale stands for painful. If the patient is responsive to pain they should withdraw from it.

Review (1 of 2) The AVPU scale is used to monitor a patient’s level of consciousness. What does the “P” stand for? Pallor Rationale: Pallor means that the skin is pale. This has nothing to do with level of consciousness. Pediatrics Rationale: The same AVPU scale is used for adults and pediatrics.

Review (2 of 2) The AVPU scale is used to monitor a patient’s level of consciousness. What does the “P” stand for? Painful Rationale: Correct answer Positioning Rationale: The patient’s position may provide clues to the patient’s condition but it is not part of the AVPU scale.

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