Seattle/King County EMT-B Class

Topics

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Pediatric Emergencies: Chapter 31

Pediatric Assessment: Chapter 32

3 Pediatric SICK/NOT SICK

1 Pediatric Emergencies

Airway Differences• Larger tongue

relative to the mouth

• Larger epiglottis • Less well-

developed rings of cartilage in the trachea

• Narrower, lower airway

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Breathing Differences

• Infants breathe faster than children or adults.

• Infants use the diaphragm when they breathe.

• Sustained, labored breathing may lead to respiratory failure.

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Circulation Differences

• The heart rate increases for illness and injury.

• Vasoconstriction keeps vital organs nourished.

• Constriction of the blood vessels can affect blood flow to the extremities.

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Skeletal Differences1

• Bones are weaker and more flexible.• They are prone to fracture with

stress.• Infants have two small openings in

the skull called fontanels.• Fontanels close by 18 months.

Growth and Development

Thoughts and behaviors of children usually grouped into stages:

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• Infancy• Toddlers• Preschool• School age• Adolescence

Infant—First year of life• They respond mainly

to physical stimuli.• Crying is a way of

expression.• Usually prefer to be

with caregiver.• If possible, have

caregiver hold the infant as you start your examination.

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Toddler—1 to 3 years of age• They begin to walk

and explore the environment.

• They may resist separation from caregivers.

• Make any observations you can before touching a toddler.

• They are curious and adventuresome.

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Preschool—3 to 6 years of age• They can use simple language

effectively.• They can understand directions.• They can identify painful areas

when questioned.• They can understand when you

explain what you are going to do using simple descriptions.

• They can be distracted by using toys.

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School Age—6 to 12 years of age• They begin to think like adults.

• They can be included with the parent when taking medical history.

• They may be familiar with physical exam.

• They may be able to make choices.

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Adolescent—12 to 18 years of age• They are very concerned about body

image.• They may have strong feelings about

being observed.• Respect an adolescent’s privacy.• They understand pain.• Explain any procedure that you are

doing.

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Family Matters• When a child is ill or injured, you

have several patients, not just one.• Caregivers often need support when

medical emergencies develop.• Children often mimic the behavior of

their caregivers.• Be calm, professional, and sensitive.

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Pediatric Emergencies

Dehydration• Vomiting and diarrhea• Greater risk than adults

Fever• Rarely life threatening• Caution if occurring with

rash

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Pediatric Emergencies, cont'd1

Meningitis• Inflammation of the tissue that

covers the spinal cord and brain.

• Caused by an infection.• If left untreated can lead to

brain damage or death.

Febrile seizures• Common between 6 months and

6 years• Last less than 15 minutes

Poisoning• Signs and symptoms vary widely.• Determine what substances were

involved.

1 Pediatric Emergencies, cont'd

Physical Differences

• Children and adults suffer different injuries from the same type of incident.

• Children’s bones are less developed than an adult’s.

• A child’s head is larger than an adult’s, which greatly stresses the neck in deceleration injuries.

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Psychological Differences

• Children are not as psychologically mature.

• They are often injured due to their undeveloped judgment and lack of experience.

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Injury Patterns: Automobile Collisions• The exact area of

impact will depend on the child’s height.

• A car bumper dips down when stopping suddenly, causing a lower point of impact.

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Injury Patterns: Sports Activities• Head and neck injuries can occur

from high-speed collisions during contact sports.

• Immobilize the cervical spine.• Follow local protocols for helmet

removal.

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Head Injuries

• Common injury among children• The head is larger in proportion

to an adult.• Nausea and vomiting are signs of

pediatric head injury.

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Chest Injuries• Most chest injuries in

children result from blunt trauma.

• Children have soft, flexible ribs.

• The absence of obvious external trauma does not exclude the likelihood of serious internal injuries.

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Abdominal Injuries• Abdominal injuries are very common

in children.• Children compensate for blood loss

better than adults but transition into shock more quickly.

Watch for:• Weak, rapid pulse• Cold, clammy skin• Poor capillary refill

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Injuries to the Extremities• Children’s bones bend more

easily than adults’ bones. • Incomplete fractures can occur.• Do not use adult splinting

devices on children unless the child is large enough to meet the required objectives.

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PASG

Pneumatic Anti-shock Garments We don't use them in King County.

They're being mentioned now because the state exam may have a few questions about them.

This has been a public service announcement…=-)

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Burns

• Most common burns involve exposure to hot substances.

• Suspect internal injuries from chemical ingestion when burns are present around lips and mouth.

• Infection is a common problem with burns.

• Consider the possibility of child abuse.

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Submersion Injury

• Drowning or near drowning• 2nd most common cause of

unintentional death of children in the US

• Assessment and reassessment of ABCs are critical.

• Consider the need for C-spine protection.

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SIDSSudden Infant Death Syndrome

Several known risk factors:• Mother younger than 20 years old• Mother smoked during pregnancy• Low birth weight

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Tasks at Scene

• Assess and manage the patient.• Communicate with and support

the family.• Assess the scene.

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Assessment and Management• Assess ABCs and provide

interventions as necessary.• If child shows signs of postmortem

changes, call medical control.• If there is no evidence of

postmortem changes, begin CPR immediately.

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Communication and Support

• The death of a child is very stressful for the family.

• Provide support in whatever ways you can.

• Use the infant’s name. • If possible, allow the family time

with the infant.

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Scene AssessmentCarefully inspect the environment, following local protocols.

Concentrate on:• Signs of illness• General condition of the house• Family interaction• Site where infant was discovered

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Apparent Life-Threatening Event• Infant found not breathing, cyanotic,

and unresponsive but resumes breathing with stimulation

• Complete careful assessment.• Transport immediately.• Pay strict attention to airway

management.

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Death of a Child

• Be prepared to support the family.

• Family may insist on resuscitation efforts.

• Introduce yourself to the child’s caregivers.

• Do not speculate on the cause of death.

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Death of a Child, continued

• Allow the family to see the child and say good-bye.

• Be prepared to answer questions posed by caregivers.

• Seek professional help for yourself if you notice signs of posttraumatic stress.

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Children With Special Needs

• Children born prematurely who have associated lung problems

• Small children or infants with congenital heart disease

• Children with neurologic diseases• Children with chronic diseases or

with functions that have been altered since birth

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Tracheostomy Tube1

Artificial Ventilators

• Provide respirations for children unable to breathe on their own.

• If ventilator malfunctions, remove child from the ventilator and begin ventilations with a BVM device.

• Ventilate during transport.

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Central IV Lines1

Gastrostomy Tubes

• Food can back up the esophagus into the lungs.

• Have suction readily available. • Give supplemental oxygen if the

patient has difficulty breathing.

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Shunts

• Tubes that drain excess fluid from around brain

• If shunt becomes clogged, changes in mental status may occur.

• If a shunt malfunctions, the patient may go into respiratory arrest.

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Pediatric Assessment2

Assessment and Management • Caring for sick and injured children

presents special challenges. • EMT-Bs may find themselves

anxious when dealing with critically ill or injured children.

• Treatment is the same as that for adults in most emergency situations.

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• Take note of your surroundings.

• Scene assessment will supplement additional findings.

• Note:• Position of the patient• Condition of the home• Clues to child abuse

1. Scene Size-up

Scene Size-up2

• Decide SICK/NOT SICK (Begins before you touch the patient.)

• Determine a chief complaint.

• The Pediatric Assessment Triangle can help.

1. Scene Size-up

Initial Assessment

2. Initial Assessment

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• Should be completed on scene unless severity requires rapid transport

• Young children should be examined toe to head.

• Focused exam on non-critical patients

• Rapid exam on potentially critical patients

1. Scene Size-up

Focused History/Physical Exam

2. Initial Assessment

3. Focused History/ Physical Exam

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• Status changes frequently in children.

• The PAT can help with reassessment.

1. Scene Size-up

Detailed Physical Exam

2. Initial Assessment

3. Focused History/ Physical Exam4. Detailed Physical Exam

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• Repeat vital signs frequently.

• If child deteriorates, repeat the initial assessment.

1. Scene Size-up

Ongoing Assessment

2. Initial Assessment

3. Focused History/ Physical Exam4. Detailed Physical Exam

5. Ongoing Assessment

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Pediatric Assessment Triangle

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Assessing the ABCsAirway: position patient correctlyWork of breathing:

• Effort• Obstructions• Rate

Circulation:• Rate• Skin color,

temperature, and capillary refill

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Transport Decision

• Children under 40 lbs should be transported in a child safety seat, if the situation allows.

• Seat should be secured to the cot or captain’s chair.

• Cannot be secured to bench seat• Child may have to be transported

without a seat, depending on condition.

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Respirations

• Abnormal respirations are a common sign of illness or injury.

• Count respirations for 30 seconds.

• In children less than 3 years, count the rise and fall of the abdomen.

• Note effort of breathing.• Listen for noises.

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Pulse• In infants, feel over the

brachial or femoral area.• In older children, use the

carotid artery.• Count for at least 1 minute.• Note strength of the pulse.

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Blood Pressure

• Use a cuff that covers two thirds of the upper arm.

• If scene conditions make it difficult to measure blood pressure accurately, do not waste time trying.

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Skin Signs• Feel for temperature and

moisture.• Estimate capillary refill.

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Care of the Pediatric Airway

• Position the airway.

• Position the airway in a neutral sniffing position.

• If spinal injury is suspected, use jaw-thrust maneuver to open the airway.

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Care of the Pediatric Airway, cont'dPositioning the airway:

• Place the patient on a firm surface.

• Fold a small towel under the patient’s shoulders and back.

• Place tape across patient’s forehead to limit head rolling.

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Oropharyngeal Airways• Determine the

appropriately sized airway.

• Place the airway next to the face to confirm correct size.

• Position the airway.• Open the mouth.• Insert the airway until

flange rests against lips.• Reassess airway.

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Assessing Ventilation

• Observe chest rise in older children.• Observe abdominal/chest rise and

fall in younger children or infants.• Skin color indicates amount of

oxygen getting to organs.

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Oxygen Delivery Devices• Nonrebreathing mask at

10 to 12 L/min provides 90+% oxygen concentration.

• Blow-by technique at 6 L/min provides more than 21% oxygen concentration.

• Nasal cannula at 4 to 6 L/min provides 24% to 44% oxygen concentration.

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BVM Devices• Equipment must be the right size.

• BVM device at 10 to 15 L/min provides 90+% oxygen concentration.

• Ventilate at the proper rate and volume.

• May be used by one or two rescuers

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Airway Obstruction

Croup

• A viral infection of the airway below the level of the vocal cords

Epiglottitis

• Infection of the soft tissue in the area above the vocal cords

Foreign body airway obstructions

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Signs and Symptoms

• Stridor

• Retractions

• Nasal flaring

• Difficulty speaking

• Decreased or absent breath sounds

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Complete Airway Obstruction

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Signs and symptoms• Ineffective cough (no sound)• Inability to cry• Increasing respiratory difficulty,

with stridor• Cyanosis• Loss of consciousness

2 Removing an FBAO In a RESPONSIVE child:• Kneel behind the child.• Give abdominal thrusts.• Repeat the technique

until object comes out or the child becomes unresponsive.

Removing an FBAO, continuedIn an UNRESPONSIVE child:

• Place the child on a firm, flat surface.• Inspect the upper airway and

remove any visible object. (No blind sweeps.)

• Attempt rescue breathing.• If ventilation is still unsuccessful,

CPR with one exception:—Visualize in the airway before you

attempt ventilation.

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• Open airway again to try and see object.

• Only try to remove object if you see it.

• Attempt rescue breathing.

2Removing an FBAO, continued

2Removing an FBAO, continued• If unsuccessful,

reposition head and attempt ventilation again.

• Continue CPR with one exception:

•Visualize in the airway before you attempt ventilation.

Airway Obstruction in Infants

• If RESPONSIVE:• Deliver 5 back slaps.• Bring infant upright on

the thigh.• Give five quick chest

thrusts.• Check airway.• Repeat cycle as often as

necessary.

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2Removing an FBAO, continued• If the infant is UNRESPONSIVE: • Inspect the airway.• Attempt rescue breathing.• Reposition the airway (if needed)• If airway remains obstructed, CPR

with one exception:•Visualize in the airway before

you attempt ventilation.

TraumaExtremity injuries in children are generally managed in the same manner as those in adults.

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Trauma, continuedBe alert for airway problems on all children with traumatic injuries.Give supplemental oxygen to all children with possible:

• Head injuries• Chest injuries• Abdominal injuries• Shock

If ventilation is required, provide at 20 breaths/min.

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Immobilization• Any child with a head or back injury

should be immobilized.• Young children may need padding

beneath their torso.• Children may need padding along the

sides of the backboard.

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Immobilization in a Child Safety Seat• Assess child for

injuries and seat for visible damage.

• If child is injured or seat is damaged, remove child to another transport device

• Apply padding around child to minimize movement.

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Removing a Child from a Safety Seat• Remove both the child and the seat

from the vehicle.• Place immobilization device behind the

child.• Slide child into place on device.

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Respiratory Emergencies

Signs and Symptoms include:

• Nasal flaring

• Grunting respirations

• Use of accessory muscles

• Retractions of rib cage

• Tripod position in older children

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Emergency Care

• Provide supplemental oxygen in the most comfortable manner.

• Place child in position of comfort.

—This may be in caregiver’s lap.

• If patient is in respiratory failure, begin assisted ventilation immediately.

—Continue to provide supplemental oxygen.

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Shock

• Circulatory system is unable to deliver sufficient blood to organs.

• Many different causes• Patients may have increased heart rate,

respirations, and pale or mottled skin.• Children do not show decreased blood

pressure until shock is severe.

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Assessing Circulation• Pulse: Above 160 beats/min

suggests shock• Skin signs: Assess temperature

and moisture • Capillary refill: Is it delayed?• Color: Is skin pink, pale, ashen, or

mottled?

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Emergency Care for Shock• Ensure airway.• Give supplemental

oxygen.• Provide immediate

transport.• Continue monitoring

vital signs en route.• Contact ALS for

backup as needed.

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Seizures

• May present in several different ways

• A postictal period of extreme fatigue or unresponsiveness usually follows seizure.

• Be alert to presence of medications, poisons, and possible abuse.

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Febrile Seizures• Febrile seizures are most common in

children from 6 months to 6 years.• Febrile seizures are caused by fever.• Generally last less than 15 minutes• Assess ABCs and begin cooling

measures.• Provide prompt transport.

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Emergency Care for Seizures

• Perform initial assessment, focusing on the ABCs.

• Securing and protecting the airway is the priority.

• Place patient in the recovery position.

• Be ready to suction.

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Emergency Care for Seizures

• Deliver oxygen by mask, blow-by, or nasal cannula.

• Begin BVM ventilation if no signs of improvement.

• Call ALS for backup if appropriate.

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Dehydration• Determine if child is vomiting or has

diarrhea and for how long.• “How many wet diapers has the child

had during the day?” (6 to 10 is normal)

• “What fluids are the child taking?”• “What was the child’s weight before

the symptoms started?”• “Has the child been normally active?”

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Emergency Care for Dehydration• Assess the ABCs.

• Obtain baseline vital signs.

• ALS backup may be needed for IV administration.

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• What questions do you have?

Questions

To review this presentation, go to:http://www.emsonline.net/emtb

To review this presentation, go to:http://www.emsonline.net/emtb