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 DevelopmentThoughts 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 EmergenciesDehydration

• 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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PASGPneumatic Anti-shock GarmentsWe 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 Exam

4. 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 Exam

4. Detailed Physical Exam

5. Ongoing Assessment

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Pediatric Assessment Triangle2

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'd

Positioning 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 ObstructionCroup

• 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 cordsForeign 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 2

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.

2 Removing an FBAO, continued

2 Removing 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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2 Removing 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 EmergenciesSigns 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