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Infants and Children

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Title: Infants and Children


1

CHAPTER 31
Infants and Children
2

Developmental Characteristics
3

Classification of Children
Age (yr.) Described as
Newborns/Infants Toddlers Preschool School-aged Ad
olescents
Birth-1 1-3 3-6 6-12 12-18
4
Behavioral Traits by Age
Newborns and Infants (birth to 1 year)
  • Tolerate parental separation poorly
  • Exhibit minimal anxiety over presence of
    strangers
  • Accept undressing, but want to feel warm
  • Can track movement visually
  • Do not tolerate oxygen masks

5
Assessment of Children
Newborns and Infants (birth to 1 year)
  • Have a parent hold the infant during the
    physical exam.
  • Keep hands tools warm.
  • Observe breathing from a distance.
  • Examine the head last.
  • If listening to lungs, do it early
  • (before child is upset)

6
Behavioral Traits by Age
Toddlers (1-3 years)
  • Do not tolerate parental separation
  • Do not like to be touched
  • May perceive illness as punishment
  • Sensitive about modesty
  • Easily frightened (i.e., by needles)
  • Tend to be perceptive, independent
  • Do not tolerate masks

7
Assessment of Children
Toddlers (1-3 years)
  • Have a parent hold the child during the
    physical exam.
  • Explain that the child was not bad.
  • If clothing is removed, replace it.
  • Try to examine the head last. Trunk to toe
    exam.
  • Explain what you do in advance but use a
    childs terms.

8
Behavioral Traits by Age
Preschool (3-6 years)
  • Do not tolerate parental separation
  • Do not like to be touched
  • Sensitive about modesty
  • May perceive illness as punishment
  • Tend to fear blood, pain, and permanent
    injury or disfigurement
  • Curious, communicative, cooperative
  • Do not tolerate masks

9
Assessment of Children
Preschool (3-6 years)
  • Have a parent hold the child during the
    physical exam.
  • If clothing is removed, replace it.
  • Be calm, reassuring, and respectful.
  • Explain what you do in advance.
  • Allow the child to give the history.
  • Avoid fastening a face mask.

10
Behavioral Traits by Age
School Age (6-12 years)
  • Cooperative, but expect to have opinions
    heard
  • Sensitive about modesty
  • Tend to fear blood, pain, and permanent
    injury or disfigurement

11
Assessment of Children
School Age (6-12 years)
  • Allow the child to give the history.
  • Explain as you examine.
  • Be calm, reassuring, and respectful.
  • Respect the childs modesty.

12
Behavioral Traits by Age
Adolescent (12-18 years)
  • Expect to be treated as adults.
  • Generally act as though indestructible.
  • May fear lasting disfigurement.
  • Variable emotional and physical development
    may produce some insecurity about self-image.

13
Assessment of Children
Adolescent (12-18 years)
  • Try to respect the emerging adult, yet
    reassure the remaining child.
  • Explain as you examine.
  • Be calm, reassuring, and respectful.
  • Respect the young adults modesty and need
    for privacy. May want to be assessed away from
    parent/guardians/adults

14

Anatomical Differences
15
Airway Differences between Adults and Children

16
Airway Differences between Adults and Children
(Airway)
  • More anterior than the adult - less head tilt
    needed to open the airway.
  • Smaller airway than adult - blocked easily by
    secretions or blood
  • Large tongue in relation to jaw size - likely to
    cause obstruction when child is unresponsive.
  • Infants prefer to breathe through their nose -
    nasal obstruction can cause respiratory distress.

17
Head
  • Bigger, softer.
  • Infants and small children have
    disproportionately larger heads (until about age
    4). Note the effect of padding.

18
Airway Differences between Adults and Children
(Breathing)
  • Small children are dependent upon contraction of
    the diaphragm to breathe
  • Children in respiratory distress compensate
    rapidly by increasing their rate of breathing and
    using their accessory muscles, which causes
    fatigue.
  • Increased work of breathing is demonstrated by
    nasal flaring and intercostal retractions.
  • Slow pulse (Bradycardia) is a sign of hypoxia in
    the pediatric patient.

19
Airway Differences between Adults and Children
(Circulation)
  • Children compensate rapidly in shock by
    increasing heart rate and vasoconstricting then
    decompensate rapidly.
  • Perfusion in the child is assessed by determining
    the heart rate, distal pulses, mental status,
    capillary refill and skin color and temperature.
  • Hypovolemia can develop from vomiting and/ or
    diarrhea in children.
  • Blood pressure is a poor indicator of perfusion
    status in the pediatric patient.


20

Airway
21
Airway Opening
  • Position to open airway is different
    head-tilt/chin-lift do not hyperextend
  • Jaw thrust with spinal immobilization if trauma
    is suspected


22
Opening the Airway Use head-tilt, chin-lift
without hyperextension.

23

Suctioning
  • Ensure small enough catheter.
  • Do not insert too deeply.
  • Suction as briefly as possible no more than 10
    seconds.

24

Signs of Partial Airway Obstruction
  • Stridor, crowing, or noisy respirations
  • Retractions on inspiration
  • Pink mucous membranes and nail beds
  • Alert

25
Treating Partial Airway Obstruction
  • Place in position of comfort (parents lap okay).
  • Administer high-concentration oxygen.
  • Transport without agitating.

26

Signs of Complete Airway Obstruction
  • No crying or speech
  • Initial difficulty breathing that worsens
  • Cough becomes weak and ineffective
  • Altered mental status, unconsciousness

27
Clearing Foreign Body Obstructions

Attempt artificial ventilation with BVM.
28

Oral Airways
  • Adjunct, not for initial artificial ventilation
  • Should not have gag reflex
  • Use correct size.
  • Use tongue depressor to hold down tongue.
  • Insert right-side-up (not upside-down).

29

Oral Airway Insertion
  • Insert tongue blade to the base of the tongue
  • Push down against the tongue while lifting
    upward
  • Insert oropharyngeal airway without rotation
    following oropharyngeal curvature

30

Nasal Airways
  • Adjunct not for initial artificial ventilation
  • Use proper size.
  • Insertion technique same as for adult.
  • Do not use if facial or head trauma exists.

31

Oxygen Therapy
32

Nonrebreather Mask
33

Blow-By Technique
  • Hold tubing no more than 2 inches from face OR
  • Insert tubing into paper cup.

34

Blow-By Technique
Do not use styrofoam cup.
35

Artificial Ventilation
  • Use proper size mask and bag.
  • If trauma involved, use jaw thrust (not head
    tilt).
  • If unable to maintain mask seal with one hand,
    use two.

36

Mouth-To-Mask Ventilation
37

Artificial Ventilation
  • Bag-Valve-Mask Use
  • Squeeze bag slowly/evenly until chest rises
    adequately.
  • If under 8 years old, ventilate 20 times a minute
    (1 breath every 3 seconds).
  • If over 8 years old, ventilate 10-12 times a
    minute (1 breath every 5 seconds).
  • Provide oxygen at 100 by using an oxygen
    reservoir

38

Head
  • Fontanelles (soft spots) exist until about 12-18
    months old.
  • Sunken may indicate dehydration
  • Bulging may indicate crying or head injury

39

Chest Abdomen
  • Increased elasticity of chest
  • Primarily abdominal breathers (infants primarily
    nose-breathers)
  • Less protection than adults for internal organs

40

Body Surface
  • Larger in proportion to body mass
  • Increased risk of hypothermia
  • Burn injuries calculated differently

41

Techniques of Pediatric Care
42

Assessment
Two methods Pediatric Assessment Triangle
(PAT) OR Step-by-Step assessment
43

Pediatric Assessment Triangle
44

PAT General Impression
  • From the Doorway
  • Observe appearance
  • Mental status
  • Body position/Muscle tone
  • Observe breathing effort.
  • Observe circulation (skin color).

45

PAT Hands-On
  • Assess and treat based on doorway assessment.
  • Provide interventions and assess for any further
    concerns.

46

Step-by-Step Assessment
47

General Principles
  • Children differ from adults, but also differ from
    each other depending on age
  • Large amount of clinical information can be
    obtained by observation before approaching the
    child
  • Child often anxious and scared by presence and
    examination of EMT as opposed to adults who are
    often relieved

48

General Principles
  • It is important to maintain a calm and relaxed
    manner when dealing with a pediatric patient
  • Speak softly (It is a known fact that monsters
    and mean people speak loudly)
  • Use the childs name
  • Adjust your height to the childs (Monsters are
    most threatening when they tower over you)
  • Look before you touch, and touch gently (Monsters
    are rough)
  • Tell the child what you are going to do then do
    it immediately
  • Never lie to a parent or a child or you will lose
    their trust
  • Enlist the parents (care givers) help
  • Attempt to keep the parent and child together

49

General/Initial Impression
  • Ensure scene safety/Take BSI precautions.
  • Begin actively observing the child from the
    doorway
  • Much of the assessment can be performed prior to
    touching (thereby upsetting the child)

50

General/Initial Impression
  • Ensure scene safety/Take BSI precautions.
  • Begin actively observing the child from the
    doorway
  • Pay particular attention to
  • Mental status
  • Skin Color
  • Effort of breathing

51

General Impression
  • The well versus sick child versus very sick
  • Mental Status
  • How is the child interacting with environment and
    parents (including eye contact)
  • What is the childs behavior?
  • What is the childs response to the EMT?
  • Tone/body position
  • Flaccid?
  • Is the child able to maintain an upright
    position?
  • Tripod Positioning?

52

General Impression
  • The well versus sick child versus very sick
  • Color
  • Pink?
  • Pale?
  • Cyanosis?
  • Respiratory rate and effort
  • What is the respiratory rate?
  • Is the chest rising and falling normally?
  • How much effort is the child making just to
    breathe?
  • Is the breathing noisy?

53

Primary Assessment
  • Detection of life threatening problems and
    treatment
  • Responsiveness
  • Stabilize cervical spine
  • Establish unresponsiveness

54
Primary Assessment
  • Airway
  • Is the child speaking or does the child have a
    vigorous cry? If not then position head
  • Trauma - Neutral with jaw thrust
  • Medical - Sniffing or Sniff Plus
  • OPA insertion as necessary

55
Primary Assessment
  • Airway contd
  • Is stridor (indicates upper airway obstruction)
    or other evidence of upper airway obstruction
    present ?
  • Foreign body - FBAO procedure as per AHA
    guidelines
  • Swelling due to disease - Possibly croup or
    epiglottitis
  • Serious medical emergency
  • Do not agitate child
  • Maintain position of comfort
  • If necessary assist ventilations with a BVM

56
Primary Assessment
  • Airway contd
  • Is gurgling / snoring present?
  • Excessive secretions require suctioning
  • Obstruction with the tongue requires
    repositioning of the head or insertion of OPA /
    NPA as indicated

57

Initial Assessment
  • Assess breathing
  • What is the respiratory rate ?
  • Is chest rise adequate ?
  • What is the respiratory effort ?
  • Increased work of breathing
  • Retractions
  • Nasal flaring
  • What are the breath sounds ?
  • Listen at mid-axillary line for equality and
    abnormal breath sounds

58
Initial Assessment
  • Assess breathing contd
  • Is oxygenation / ventilation adequate ?
  • Cyanosis - Central versus peripheral
  • Altered Mental State
  • If oxygenation is inadequate provide
    supplemental oxygen
  • Non-Rebreather Mask (if tolerated) with 10-15
    LPM flow rate
  • Blow-by Oxygen with oxygen tubing at 6 LPM flow
    rate
  • If ventilations are inadequate provide assisted
    ventilations
  • BVM with a reservoir
  • Are there signs of trauma to the chest ?
  • Seal holes
  • Stabilize fractures

59
Initial Assessment
  • Assess circulation
  • Assess the rate and quality of peripheral pulses
  • Diminished or absent peripheral pulses indicates
    compensated shock especially in the presence of a
    strong central pulse.
  • Absence of central pulses (femoral or in
    children older than one year brachial) indicates
    decompensated shock
  • Absence of carotid pulse (brachial in infants)
    indicates cardiac arrest
  • Assess capillary refill
  • Normal is less than 2 seconds
  • Delayed (2-4 seconds) is seen with compensated
    shock
  • Absent (greater than 4 seconds) is seen with
    decompensated shock

60
Initial Assessment
  • Assess circulation
  • Assess skin color and temperature
  • Pale and/or cool skin can indicate shock
  • Is shock present ? If present is it compensated
    or decompensated
  • Is their signs / symptoms of internal and/or
    external bleeding ?
  • Blood pressure is difficult to measure in
    pediatric patients and is of limited value
  • Support circulation as necessary
  • Control bleeding
  • Elevate the legs in the absence of trauma
  • Maintain body temperature

61
Initial Assessment
  • Assess disability
  • Altered mental status is indicative of hypoxia or
    hypoperfusion
  • Assess the level of consciousness
  • Mental status evaluation is dependent on the
    patients age
  • AVPU scale
  • Assess pupils and ability to move all four
    extremities
  • If collar has not been applied and is indicated,
    apply a rigid extrication collar

62
Initial Assessment
  • Expose
  • Attempt to locate all injuries
  • Maintain body temperature
  • CUPS Decision Use pediatric CUPS status

63

Identify Priority Patients
  • Poor general impression
  • Unresponsive
  • Airway compromise
  • Inadequate breathing
  • Shock
  • Uncontrolled bleeding

64

Focused History
  • Child may be only source.
  • Use simple yes/no questions.
  • Use parents/guardians for information if possible.

65

Detailed Physical Exam
  • Generally, start at trunk and evaluate head last.
  • Alter order of steps to fit situation.
  • Avoid making child more anxious.

66

Ongoing Assessment
  • Reassess interventions.
  • Reassess ABCs.
  • Reassess vital signs.
  • Continuous reassessment is key!

67

Newborn Assessment and Management
68
Newborn Assessment/Management
  • Importance
  • Newborn resuscitation needs to be provided
    immediately following delivery which is most
    likely to be provided by the first responder
  • Parents most likely will not have the skills or a
    good hold of the situation to perform the
    necessary skills

69
Newborn Assessment
  • Respiratory Effort
  • What is the respiratory rate?
  • Respiratory Effort
  • Are there retractions, nasal flaring, chest wall
    movement, etc
  • Skin Color
  • Peripheral cyanosis is normal in the newborn
  • Central or persistent cyanosis is worrisome

70
Newborn Assessment
  • Perfusion
  • Heart rate
  • Assess by palpating umbilical cord or listening
    with stethoscope for heartbeat
  • Skin Color
  • Muscle Tone
  • The newborn should have a normal grasp and
    movement of all extremities

71
Newborn Management
  • Warm and Dry
  • All newborns require warming and drying, this
    alone may stimulate breathing
  • Suctioning
  • All newborns require suctioning of the mouth and
    nose
  • Suctioning will stimulate the newborn to breathe
  • Always suction the mouth before the nose to
    prevent aspiration
  • Tactile Stimulation
  • After warming, drying and suctioning if the
    newborn has a poor or absent respiratory effort
    they may need to be stimulated
  • Tactile stimulation is accomplished by either
    rubbing the back or flicking the soles of the
    newborn

72
Blow-by Oxygen/Assisted Ventilations
  • Most newborns do not require supplemental oxygen
    or assisted ventilations
  • Blow-by oxygen should be provided for the newborn
    who has either central cyanosis or prolonged
    peripheral cyanosis AND a normal respiratory
    effort and a heart rate above 100
  • If the indications for blow-by oxygen resolve the
    blow-by oxygen should be gradually withdrawn
  • Assisted ventilations should be provided to any
    newborn with either
  • Heart rate below 100
  • Absent or poor respiratory effort despite
    warming, drying, suctioning and stimulating the
    newborn
  • Cyanosis which has not improved with blow-by
    oxygen
  • If the newborns indications for assisted
    ventilations resolve ventilations should be
    stopped and blow-by oxygen provided

73
Chest Compressions
  • Rarely does a newborn require chest compressions
  • If the newborns heart rate is either below 80
    and not improving despite warming, drying,
    tactile stimulation and 30 seconds of BVM
    ventilation, begin, chest compressions

74

Common Medical Problems
75
Airway Obstructions
  • Partial Airway Obstruction infant or child who
    is alert and sitting
  • Stridor, crowing, or noisy
  • Retractions on inspiration
  • Pink
  • Good peripheral perfusion
  • Still alert, not unconscious
  • Emergency medical care
  • Allow position of comfort, assist younger child
    to sit up, do not lay down. May sit on parents
    lap.
  • Offer oxygen
  • Transport
  • Do not agitate child
  • Limited exam. Do not assess blood pressure.

76
Airway Obstructions
  • Complete Airway Obstruction and altered mental
    status or cyanosis and partial obstruction
  • No crying or speaking and cyanosis.
  • Child's cough becomes ineffective
  • Increased respiratory difficulty accompanied by
    stridor
  • Victim loses consciousness
  • Altered mental status
  • Clear airway.
  • Infant foreign body procedures
  • Child foreign body procedures
  • Attempt artificial ventilations with a
    bag-valve-mask and good seal.

77

Respiratory Emergencies
  • Common causes are
  • Aspiration of foreign objects
  • Respiratory diseases and infections
  • Near drowning or electrocution
  • Poisonings
  • SIDS

78

Respiratory Emergencies
  • Upper Airway Obstruction
  • Stridor on inspiration
  • Lower Airway Disease
  • Wheezing and breathing effort on exhalation
  • Rapid breathing without stridor
  • Know respiratory rates for age

79

Complete Airway Obstruction
  • No crying
  • No speaking
  • Cyanosis is present
  • No couging

80

Respiratory Assessment
  • Check respiratory rate
  • Rate can be affected by many factors such as
    fear, fever and age
  • Initial response to respiratory distress is an
    increased respiratory rate, followed by a drop in
    the respiratory rate as the child fatigues
  • Assess respiratory effort
  • Chest rise
  • Retractions
  • Nasal flaring

81

Respiratory Assessment
  • Auscultate breath sounds
  • Should be performed at the mid-axillary line
  • Sounds on inspiration usually indicate upper
    airway problems while sounds with expiration
    usually represent lower airway problems
  • Look for asymmetry
  • Wheezes are a sign of small airway narrowing and
    reduced air flow
  • Inspect and palpate the chest
  • Are there any visible signs of trauma
  • Assess Skin Color
  • Central or peripheral cyanosis

82

Respiratory Distress
  • Recognize signs of increased effort or breathing
    needs a NRB mask
  • Early respiratory distress is indicated by any of
    the following
  • Nasal flaring
  • Intercostal Retractions (neck muscles),
    supraclavicular (above clavicles), subcostal
    retractions (below ribs)
  • Stridor
  • Neck and abdominal muscles retractions
  • Audible wheezing
  • Grunting

83

Respiratory Distress
  • The presence of signs and symptoms of early
    respiratory distress and any of the following
  • Rate gt60
  • Cyanosis
  • Decreased muscle tone
  • Severe use of accessory muscles
  • Poor peripheral perfusion and color
  • Altered mental status
  • Alert, irritable, anxious
  • Grunting

84

Signs of Respiratory Distress
85

Respiratory Arrest/Failure
  • Needs assisted BVM assisted ventilations. Use
    the patients as medical control (i.e. any
    pediatric patient who will tolerate a BVM needs a
    BVM)
  • Difficulty with breathing
  • Increased respiratory effort at sternal notch
  • Breathing rate less than 10 per minute
  • Retractions
  • Head bobbing
  • Grunting
  • Severe accessory muscle use
  • Absent or shallow chest wall motion

86
Respiratory Arrest/Failure
  • Needs assisted BVM assisted ventilations. Use
    the patients as medical control (i.e. any
    pediatric patient who will tolerate a BVM needs a
    BVM)
  • Difficulty with breathing contd
  • Limp muscle tone
  • Decreased muscle tone or poor muscle tone (e.g.
    unable to maintain sitting position in infant gt 4
    months)
  • Change in Mental Status
  • Sleepy
  • Intermittently combative
  • Agitated
  • Unresponsive to voice or touch
  • Unconscious

87
Respiratory Arrest/Failure
  • Needs assisted BVM assisted ventilations. Use
    the patients as medical control (i.e. any
    pediatric patient who will tolerate a BVM needs a
    BVM)
  • Difficulty with breathing contd
  • Slower, absent heart rate
  • Difficulty with color/perfusion
  • Central cyanosis
  • Marked tachycardia or bradycardia
  • Poor peripheral perfusion
  • Weak or absent distal pulses.
  • Respiratory ailments are the primary cause of
    cardiac arrest, not due to trauma

88

Respiratory Emergencies
  • Maintain the airway
  • Provide high-concentration oxygen to all children
    with resp. emergencies
  • Provide oxygen and assist ventilations if
    respiratory distress is severe
  • Altered mental status
  • Cyanosis not improving with oxygen
  • Poor muscle tone
  • Respiratory failure
  • Respiratory arrest apply oxygen and ventilate
    wit BVM

89

Croup
  • Viral inflammation of trachea larynx
  • Usually affects ages 6 months to 4 years
  • Onset typically at night
  • Seal-like barking cough
  • Signs of respiratory distress

90

Treatment of Croup
  • Place in position of comfort.
  • Administer high-concentration oxygen.
  • Cool air may provide relief.
  • Transport.

91

Epiglottitis
  • A life-threatening emergency!
  • Bacterial inflammation of epiglottis
  • Usually affects ages 3 to 7
  • Sudden onset of high fever

Continued
92

Epiglottitis
  • A life-threatening emergency!
  • Tripod positioning
  • Painful swallowing respiratory distress

93

Treatment of Epiglottitis
  • Place in position of comfort.
  • Administer high-concentration oxygen.
  • Transport immediately.
  • Do not increase childs anxiety.
  • Do not place anything in patients mouth.

94

Seizures
  • Seizures in children who have chronic seizure are
    rarely life-threatening. However, seizures,
    including febrile, should be considered life-
    threatening by the EMT-B
  • May be brief or prolonged
  • Assess for presence of injuries which may have
    occurred during the seizures

95

Seizures
Causes
  • Fever
  • Infection
  • Poisoning
  • Hypoglycemia
  • Trauma
  • Hypoxia
  • Idiopathic (Unknown Cause)

96

Assessing Seizures
  • History of Seizures
  • Has child had seizures before?
  • If yes, is this the childs normal seizure
    pattern?
  • Anti-seizure medication taken?
  • Any fever?

97

Treatment of Seizures
  • Assure patency of airway.
  • Position patient on side if no possibility of
    cervical spine trauma. Protect from injury.
  • Have suction ready.
  • Provide oxygen and if in respiratory arrest or
    severe respiratory distress, assure airway
    position and patency and ventilate with BVM.
  • Transport. Although brief seizures are not
    harmful, there may be a more dangerous underlying
    condition.

98

Seizures
  • Can be caused by head injury
  • Inadequate breathing and/or altered mental status
    may occur following a seizure.

99

Altered Mental Status
Causes
  • Hypoglycemia
  • Poisoning
  • Post-seizure
  • Infection
  • Head trauma
  • Hypoxia
  • Shock

100
Emergency Care of Altered Mental Status
  • Establish airway.
  • Administer high-concentration oxygen.
  • Be prepared to artificially ventilate and suction
    as needed.
  • Consider spinal precautions.
  • Transport.

101

Poisonings
  • Common reason for infant and child ambulance
    calls
  • Identify suspected container through adequate
    history. Bring container to receiving facility if
    possible.
  • Emergency medical care
  • Responsive patient
  • Contact medical control.
  • Provide oxygen.
  • Transport.
  • Continue to monitor patient - may become
    unresponsive.

102

Poisonings
  • Emergency medical care contd
  • Unresponsive patient
  • Assure patency of airway.
  • Be prepared to artificially ventilate.
  • Provide oxygen if indicated.
  • Call medical control.
  • Transport.
  • Rule out trauma, trauma can cause altered mental
    status.

103

Fever
  • Common reason for infant or child ambulance call
  • Many causes rarely life-threatening. A severe
    cause is meningitis
  • Fever with a rash is a potentially serious
    consideration
  • Transport and be prepared for seizures.

104

Shock (Hypoperfusion)
Common Causes
  • Diarrhea and dehydration
  • Trauma
  • Vomiting
  • Blood loss The loss of any amount of blood in
    an infant or child can be life-threatening
  • Infants 50ml
  • Infection
  • Abdominal injuries

105

Blood Volume
106

Shock (Hypoperfusion)
Uncommon Causes
  • Allergic reactions
  • Poisoning
  • Cardiac problems

107

Assessment of Shock
  • Different than for adults
  • Blood pressure hard to measure and unreliable,
    especially true when lt 3 years old, don't even
    obtain BP measurement
  • Key assessment is peripheral perfusion and mental
    status
  • Be aware that shock in a child can rapidly
    deteriorate
  • Diminished or absent peripheral pulses indicates
    compensated shock especially in the presence of a
    strong central pulse.

108

Signs and Symptoms of Shock
  • Compensated Shock
  • Altered Mental Status
  • Rapid pulse (tachycardia)
  • Cool extremities
  • Weak/absent peripheral pulses
  • Delayed capillary refill

Continued
109

Signs and Symptoms of Shock
  • Decompensated Shock
  • Weak or impalpable central pulses
  • Extensive cyanosis of all extremities
  • Absence of tears even when crying
  • Systolic BP less than 70mmHg

110

Signs of Shock
111
Treating Shock
  1. Assure airway/oxygen
  2. Provide supplemental oxygen
  3. Be prepared to artificially ventilate
  4. Manage bleeding if present
  5. Immobilize the patient as indicated
  6. Elevate legs if no indication of trauma
  7. Keep warm
  8. Transport.

Rapid transport form infant/child with
secondary exam en route
112
Emergency Care for Near Drowning
  • Artificial ventilation is top priority
  • Consider possibility of trauma
  • Consider possibility of hypothermia
  • Consider possible ingestion, especially alcohol
  • Protect airway, suction if necessary
  • Secondary drowning syndrome - Deterioration after
    breathing normally from minutes to hours after
    event. All near drowning victims should be
    transported to the hospital.

113

Key Term
Sudden Infant Death Syndrome (SIDS)
Sudden death without identifiable cause in infant
lt 1 year old. Cause is not well understood. Most
common time of discovery is early morning.
114

Emergency Care of SIDS
  • Resuscitate if indicated - unless rigor mortis is
    present.
  • Parents will be in agony from emotional distress,
    remorse and imagined guilt.
  • Avoid comments that blame parents.

115

Trauma
116

In the United States, injuries kill more children
and infants than any other cause of death.
117

Trauma General Considerations
  • Most pediatric trauma is blunt trauma and arises
    from falls and motor vehicle accidents
  • Blunt trauma has less overt signs and has a later
    deterioration than penetrating trauma, therefore
    rely on the mechanism in the absence of overt
    signs and / or symptoms of serious trauma
  • Children have relatively large liver and spleen
    and have poor muscle protection of these organs
    making them extremely susceptible to injury

118

Trauma General Considerations
  • Head trauma is more prevalent in children because
    of the larger head to body ratio when compared
    with adults
  • Infants can lose enough blood in their head to
    develop decompensated shock
  • Pediatric head injury patients usually die from
    airway and ventilatory problems and not the
    actual head injury. As such control the airway
    and ventilation
  • Pelvic fractures can cause enough blood loss in
    the pediatric shock to cause hypovolemic shock
  • What may seem like a small blood loss may be
    relatively extensive when compared to the childs
    smaller blood volume

119

Blunt Trauma Most Common Type of Injury
  • Pattern of Injury will be different from adults
  • Motor vehicle crashes
  • Unrestrained passenger (head and neck injuries)
  • Restrained passenger (abdominal and lower spine
    injuries)

120

Blunt Trauma
  • Motor vehicle impacts
  • Struck while riding bicycle (head, abdominal,
    spinal injuries)
  • Pedestrian struck by vehicle (abdominal injury
    with internal bleeding, possible painful,
    swollen, deformed thigh, head injury)

121

Blunt Trauma
  • Falls from height, diving into shallow water
  • Head and neck injuries
  • Burns
  • Sports injuries head and neck
  • Child abuse

122

Blunt Trauma Specific Types of Injuries
  • Head
  • The single most important maneuver is to assure
    an open airway by means of the modified jaw
    thrust combined with a neutral head position.
  • Children are likely to sustain head injury along
    with internal injuries. Signs and symptoms of
    shock (hypoperfusion) with a head injury should
    cause you to be suspicious of other possible
    injuries.
  • Respiratory arrest is common secondary to head
    injuries and may occur during transport.

123

Blunt Trauma Specific Types of Injuries
  • Head contd
  • Common signs and symptoms are nausea and
    vomiting.
  • Most common cause of hypoxia in the unconscious
    head injury patient is the tongue obstructing the
    airway. Jaw-thrust is critically important.
  • Do not use sandbags to stabilize the head because
    the weight on child's head may cause injury if
    the board needs to be turned for emesis.

124

Blunt Trauma Specific Types of Injuries
  • Pediatric Cervical Spinal Stabilization and
    Immobilization
  • Manual stabilization
  • Initially provide manual stabilization while
    maintaining an adequate airway
  • Cervical Collars
  • Initially assure that the head is in a neutral
    position
  • Choose a collar of appropriate size based on
    manufacturers recommendations
  • Towels can be used in place of a cervical collar
    for infants that do not fit in the available
    collars.

125

Blunt Trauma Specific Types of Injuries
  • Spinal Immobilization
  • Immobilization of pediatric patients should
    account for their anatomical differences
  • Children are shorter than adults - use
    backboards which have strap holes at multiple
    locations or use a short backboard.
  • Children are narrower than adults - it may be
    necessary to pad along the sides to insure a snug
    fit of the straps.
  • Small children have a large occiput - pad under
    the upper torso to insure neutral alignment of
    the cervical spine.

126

Blunt Trauma Specific Types of Injuries
  • Spinal Immobilization contd
  • Assure that a cervical collar is in place prior
    to moving patient to the backboard.
  • Place a child on the backboard using standard
    patient moves for a spinal injury patient
  • Secure the chest, pelvis and knees and then the
    head

127

Blunt Trauma Specific Types of Injuries
  • Chest
  • Children have very soft pliable ribs
  • There may be significant injuries without
    external signs

128
Blunt Trauma Specific Types of Injuries
  • Abdomen
  • More common site of injury in children than
    adults
  • Often a source of hidden injury
  • Always consider abdominal injury in the multiple
    trauma patient who is deteriorating without
    external signs
  • Air in stomach can distend abdomen and interfere
    with artificial ventilation efforts

129

Blunt Trauma Specific Types of Injuries
  • Extremities
  • Managed in the same manner as adults

130

Trauma Other Considerations
  • Burns
  • Cover with sterile dressing (non-adherent, if
    possible, sterile sheets may be used).
  • Follow local protocol with regard to transport to
    burn center.

131

Emergency Care of Trauma
  • Maintain an adequate airway while manually
    stabilizing the cervical spine
  • Assure airway position and patency. Use modified
    jaw thrust.
  • Suction as necessary with large bore suction
    catheter.
  • Provide oxygen.
  • Assist ventilations for severe respiratory
    distress and ventilate with a bag-valve-mask for
    respiratory arrest.
  • Support circulation
  • Provide spinal immobilization.
  • Transport immediately.

132

Child Abuse and Neglect
133

Key Term
Abuse
Improper or excessive action so as to injure or
cause harm
134

Key Term
Neglect
Giving insufficient attention or respect to
someone who has a claim to that attention
135
  • EMTB must be aware of condition in order to
    recognize it.
  • Physical abuse and neglect are the two forms of
    child abuse EMTB is most likely to suspect.

136

Signs of Abuse
  • Multiple bruises in various stages of healing
  • Injury inconsistent with mechanism described
  • Repeated calls to the same address
  • Continued

137

Signs of Abuse
  • Fresh burns
  • Parents seem inappropriately unconcerned
  • Conflicting stories
  • Fear on the part of the child to discuss how the
    injury occurred

138

Signs of Neglect
  • Lack of adult supervision
  • Child appears malnourished
  • Unsafe living environment
  • Untreated chronic illness (i.e. asthmatic with no
    medications)

139

Handling Abuse and Neglect
  • CNS injuries are most lethal.
  • Shaken baby syndrome
  • Do not accuse anyone in the field.
  • Accusation and confrontation delays
    transportation
  • Bring objective information to the receiving
    facility

140

Handling Abuse and Neglect
  • Required Reporting
  • Follow state laws and local regulations.
  • Document objective information (what you SEE and
    HEAR, NOT what you THINK).

141

Infants and Children with Special Needs
142

Children with Special Needs
  • This can include many different types of
    children
  • Premature babies with lung disease
  • Babies and Children with heart disease
  • Infants and children with neurologic disease
  • Children with chronic disease or altered function
    from birth

143

Technologically Dependent Children (High-Tech
Kids)
  • Tracheostomy tube
  • Central intravenous lines
  • Gastrostomy tubes
  • Shunts

144
Tracheostomy Tube Complications
  • Obstruction
  • Bleeding
  • Air leak
  • Dislodged tube
  • Infection

145

Tracheostomy Tube
146

Managing the Tracheostomy Tube
  • Maintain open airway.
  • Suction.
  • Maintain a position of comfort.
  • Transport.

147

Home Artificial Ventilation
Parents are usually familiar with equipment.
148

Home Artificial Ventilation
  • Assure airway.
  • Artificially ventilate with high-concentration
    oxygen.
  • Transport.

149

Central Intravenous Lines
  • IVs that are placed near the heart for long term
    use
  • Complications
  • Cracked line
  • Infection
  • Clotting off
  • Bleeding

150

Care of Central Intravenous Lines
  • If bleeding is present, apply pressure.
  • Transport.

151

Key Term
Gastrostomy Tubes
Tube placed directly into stomach for feeding.
Comes in many shapes. These patients usually
cannot be fed by mouth.
152

Managing Gastrostomy Tubes
  • Assure adequate airway.
  • Have suction available.
  • If a diabetic patient, be alert for altered
    mental status. Infant will become hypoglycemic
    quickly if they cannot be fed.
  • Provide high-concentration oxygen.
  • Transport patient sitting or lying on right side
    with head elevated.

153

Key Term
Shunt
Device running from brain to abdomen to drain
excess cerebrospinal fluid. Will find reservoir
on side of skull.
154

Managing Shunts
  • Prone to respiratory arrest
  • Manage airway.
  • Assure adequate artificial ventilation.
  • Transport.

155

Family Response
156

A child cannot be cared for in isolation from the
family therefore, you have multiple patients.
157

Family Response
  • Striving for calm, supportive interaction with
    family will result in improved ability to deal
    with the child.
  • Calm parents calm child Agitated parents
    agitated child.
  • Anxiety arises from concern over childs pain
    fear for childs well-being
  • Worsened by state of helplessness

158

Family Response
  • Parent may respond with anger/hysteria toward
    EMTB.
  • Parents should remain part of the care unless
    child is not aware or medical conditions require
    separation.
  • Parents should be instructed to calm child can
    maintain position of comfort and/or hold oxygen.
  • Parents may not have medical training, but they
    are experts on what is normal or abnormal for
    their children and what will have a calming
    effect.

159

Provider Response
160

Provider Response
  • Anxiety from lack of experience with treating
    children as well as fear of failure.
  • Skills can be learned and applied to children.
  • Stress from identifying patient with their own
    children.
  • Provider should realize that much of what they
    learned about adults applies to children they
    need to remember the differences.

161

Provider Response
  • Infrequent encounters with sick children advance
    preparation is important (practice with equipment
    and examining children).
  • Encounters with sick or injured children may
    result in adverse emotional response by the
    EMT-B.
  • Critical Incident Stress Management (CISM)
    programs have been helpful in assisting EMS
    personnel to manage their normal response to
    these stressful situations.
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