© 2011 National Safety Council 21-1 PEDIATRIC PATIENTS LESSON 21.

© 2011 National Safety Council 21-1

PEDIATRIC PATIENTSLESSON 21


Introduction

• 5-10% of emergency responses involve children

• Children maybe unable to tell you what happened

• Because parents, family members or caretakers are often frightened and worried, communication is particularly important

• Size and anatomical difference make care different


Interacting with Infants, Children and Caretakers

• Prevent anxiety and panic in child and caretakers

• Tell child your name

• Say you are there to help

• Be especially sensitive to child’s feelings

• Ensure a parent or caretaker has been called


Interacting with Infants, Children and Caretakers (continued)

• Stay at child’s level, be friendly and calm

• Observe child for clues about how best to be reassuring

• Young child may be comforted by favorite toy or touch

• Always be honest with child and caretakers

• Keep patient and caretakers informed


Interacting with Infants, Children and Caretakers (continued)

• Don’t separate child from caretaker

• Approach slowly from a safe distance

• Talk with both caretaker and child

• Observe child and caretaker before touching child

• Remain calm


Differences in Anatomyand Physiology

• Infants and children are not small adults

• Differences from adult anatomy and physiology in most body areas


Head and Neck

• Smaller airway easily blocked

• Tongue relatively larger, can easily block airway

• When opening airway, don’t hyperextend neck

• Pad beneath shoulders to prevent flexion of neck

• Suctioning secretions from nose can improve breathing problems

• Head of infant or young child relatively larger and heavier

• “Soft spots” (fontanels) put head at greater risk


Chest and Abdomen

• Children compensate for respiratory problems or shock for short periods

• Compensation followed by rapid decompensation

• Use of accessory muscles a clear sign of breathing problem

• Slow pulse rate generally indicates hypoxia


Chest and Abdomen (continued)

• More susceptible to hypothermia

• Blood loss may be fatal

• More easily dehydrated (diarrhea or vomiting)

• Internal injuries are more likely with trauma


Extremities

• Bones easily fracturedby trauma


Assessing Infants and Children

• Assessment uses same steps as for adults

• Correct problems threatening airway, breathing or circulation as soon as found

• Assessment varies based on age and nature of problem

• Reassess continuously until emergency care is transferred


Scene Size-Up

• Begin by observing scene

• Note how child and caretakers interact

• Gather information from caretakers

• Observe the environment

• Note location and position in which patient is found


General Impression: Pediatric Triangle

• You can often tell how ill or severely injured child is from a distance in 15-30 seconds

• Remember 3 key elements: Consider child’s general

appearance Assess child’s work

of breathing Assess skin color

• These observations also help assess child’s mental status


Assess Mental Status

• Quality of crying or speaking

• Emotional state

• Behavior

• Response to caretakers

• How attentive child is to you


Possible Causes of Abnormal Findings in Triangle Assessment

• Respiratory distress or failure

• Shock

• Cardiopulmonary failure or arrest

• Other abnormal conditions


Primary Assessment

• Primary assessment follows same steps as adult


Responsiveness, Breathing, Circulation


Responsiveness

• Responsive if purposively moving, crying or speaking, or coughing

• Unless obviously responsive, tap child on shoulder and shout, “Are you OK?” or flick foot of infant

• Unresponsiveness is potentially life-threatening condition summon additional EMS resources

• If child is responsive, assess level using AVPU scale

• Assess pupil size, equality and reaction to light

• Check whether all extremities are moving equally


Breathing

• While assessing for responsiveness, look for normal breathing

• Child who can speak, cough or make other sounds is breathing and has heartbeat

• Reflex gasping (agonal respirations) is not normal breathing

• Lack of breathing may be caused by cardiac arrest, an obstructed airway or other causes

• If patient is not breathing normally, quickly check for pulse


Breathing (continued)

• If breathing, assess breathing adequacy:

Respiratory rate

Chest expansion and symmetry of movement


Breathing (continued)

• If breathing, assess breathing adequacy:

Effort of breathing: nasal flaring, retractions, grunting

Abnormal sounds: stridor, crowing


Circulation

• If not breathing, check pulse for <10 seconds

• Use femoral or carotid pulse in a child or brachial pulse in an infant

• If no pulse, start CPR and use AED


Circulation (continued)

• Assess pulse rate and strength

• Assess skin color, temperature and condition

• Reduced circulation indicated by:

- Pale, ashen or cyanotic skin color

- Cool, clammy skin

- Capillary refill time ≥2 seconds

• Begin CPR if the pulse is less than 60 beats/minute

• Assess for signs of shock and treat


Check for Severe Bleeding

• Decompensation can occur quickly in an infant or child with blood loss

• Control external bleeding immediately with direct pressure


History

• Communicate at level with child

• Gather SAMPLE information from caretakers

• Pay particular attention to signs and symptoms and their duration:

- Fever

- Activity level

- Recent eating and drinking and urine output

- Vomiting, diarrhea or abdominal pain


Vital Signs

• Vital signs of infants and children are normally different from adults

• Changes may occur quickly in infants and children, especially with decompensation

• Falling blood pressure is a late sign of shock


Normal Vital Signs

Patient Normal Respiratory Rate at Rest

Normal Pulse Rate at Rest

Normal Blood Pressure (systolic/diastolic)

Infant 30 - 40 100 - 160 70-100 / 56-70

Child 20 - 30 70 - 130 70-120 / 50-80

Adult 12 - 20 60 - 100 118-140 / 60-90


Physical Examination

• Maintain spinal immobilization in trauma or unresponsive patient

• Support head when moving infant

• Expose skin to look for injuries, but promptly cover child to prevent hypothermia; cover infant’s head

• Assess anterior fontanel on top of skull

• Examine from toe to head


Physical Examination (continued)

Especially assess:

• The head for bruising or swelling

• The ears for drainage suggestive of trauma or infection

• The mouth for loose teeth, identifiable odors and bleeding

• The neck for abnormal bruising

• The chest and back for bruise, injuries and rashes

• Extremities for deformities, swelling and pain on movement


Airway Management

• Opening airway

• Suctioning

• Using airway adjuncts


Opening the Airway of Pediatric Patients

• Be careful not to hyperextend neck when using head tiltchin lift to open airway of infant

• Put folded towel under back and shoulders for better positioning of airway

• Look inside mouth of an unresponsive infant for obstructing object

• Use jaw thrust technique for trauma patients

• Suction airway if needed


Suctioning

• Using gauze pad sweep mouth or suction

• Don’t insert tip of rigid catheter deeper than baseof tongue

• For newborn, don’t suction longer than 3-5 seconds at a time

• With an older infant or child, don’t suction longer than 10 seconds at a time


Airway Adjuncts

• Use oral airway if no gag reflex

• Remove airway if child gags, coughs, etc.

• Oral airway not for initial ventilations

• Device keeps airway open

• Select proper size

• Nasal airways are not usually inserted in children by EMRs


Oral Airway Insertion

• Insert oral airway in upright position – do not rotate 180 degrees as for adult

• Open child’s mouth

• Use tongue blade to press base of tongue down

• Insert airway in upright (anatomic) position

• If tongue blade not available, use index finger to press base of tongue down


Respiratory Emergencies


Respiratory Emergencies

• Airway obstructions

• Respiratory distress and arrest

• Respiratory infections

• Asthma


Signs and Symptoms of Mild Airway Obstructions

• Infant or child is alert and sitting

• Hear stridor, crowing, noisy breathing

• Retractions on inspiration

• Skin pink with good peripheral perfusion

• Strong pulse


Emergency Care for Mild Airway Obstructions

• Allow child to assume position of comfort

• Assist a younger child to sit up, not lie down

• Do not agitate child

• Encourage continued coughing to dislodge object

• Follow local protocol for oxygen administration


Signs and Symptoms of Severe Airway Obstructions

• No crying or speaking

• Weak and ineffective cough

• Cyanosis

• Cough that becomes ineffective

• Increased respiratory difficulty and stridor

• Altered mental status; unresponsiveness


Emergency Care for Severe Airway Obstructions

• Attempt to clear airway (finger sweep and suctioning)

• Use alternating back blows (slaps) and chest compressions in responsive infant

• Use abdominal thrusts in responsive child

• Give CPR to unresponsive infant or child


Emergency Care for Severe Airway Obstructions (continued)

• Check for object in mouth before giving a breath

• Remove any object you see

• Never perform blind finger sweep

• Attempt artificial ventilations with mouth-to-mask technique


Respiratory Distress and Arrest

• Respiratory distress is difficulty breathing

• Respiratory distress frequently leads to respiratory arrest


Signs and Symptoms of Respiratory Distress

• Gasping, speaking in shortened sentences

• Respiratory rate <30 or >60 breaths/minute in infants <20 or >30-40 breaths/minute in

children

• Nasal flaring

• Intercostal, supraclavicular, subcostal retractions

• Stridor, grunting or noisy breathing

• Cyanosis, or pale or ashen skin

• Altered mental status


Emergency Care for Respiratory Distress

• Perform standard patient care

• Allow child to assume position of comfort

• Ensure appropriate position of head and neck



Blow-by Oxygen

• Responsive infant or child may resist mask on face

• Use blow-by oxygen delivery technique

• Have caretaker hold mask about 2 inches from face


Signs and Symptoms of Respiratory Arrest

• Breathing rate:

- <20 breaths/minute in an infant

- <10 breaths/minute in a child

• Limp muscle tone

• Unresponsiveness

• Slow or absent pulse

• Weak or absent distal pulses

• Cyanosis


Emergency Care forRespiratory Arrest


• Provide ventilations by mouth or mask


• Monitor pulse and provide CPR if needed


Respiratory Infections

• Common in childhood

• Range from minor to life threatening

• May affect upper or lower airways

• Result from infection, foreign bodies, allergic conditions


Signs and Symptoms of Respiratory Problems

• Rapid breathing

• Noisy breathing

• Retractions

• Mental status changes


Croup

• Viral infection of upper/lower airway

• More frequently occurs in winter months and in evening

• More common in younger children

• Often preceded by being ill 1-2 days with or without fever

• Generally not life-threatening


Signs and Symptoms of Croup

• Hoarseness

• Stridor

• “Barking” cough

• Difficulty breathing


Emergency Care for Croup


• Difficult to distinguish from life-threatening epiglottitis

• If croup persistent, child should see physician

• Give care for respiratory distress

• Follow local protocol for humidified oxygen


Epiglottitis

• Rare, life-threatening infection of epiglottis

• Epiglottis swells and airway completely obstructed

• Occurs more frequently in children older than 4


Signs and Symptomsof Epiglottitis

• Child appears ill and frightened

• High fever

• Child is sitting up to breathe

• Saliva may drool from the child’s mouth


Emergency Care for Epiglottitis


• Don’t examine mouth or place OPA

• Allow child to remain in comfortable position



• Ensure immediate transport


Bronchiolitis

• Common cause of respiratory distress in young children

• Also called respiratory syncytial virus

• Viral infection of smaller airways causing respiratory distress and occasional hypoxia


Signs and Symptoms of Bronchiolitis

• Fever

• Nasal congestion

• Increased work of breathing with retractions and use of accessory muscles

• Markedly abnormal lung sounds with crackles and wheezes together

• May be cyanotic


Emergency Care for Bronchiolitis




• If patient has asthma medication inhaler, follow local protocol


Asthma

• Common medical problem in children

• Causes periodic attacks of difficulty breathing

• Results from an abnormal spasm of lower airways

• Attacks range from minor to life threatening


Signs and Symptoms of Asthma Attack

• Difficulty breathing, rapid irregular breathing

• Coughing, wheezing

• Exhaustion

• In severe attack:

- Altered mental status

- Cyanosis


Emergency Care for Asthma Attack




• If patient has asthma medication inhaler, follow local protocol to assist


Shock


Shock

• Commonly occurs from bleeding, traumatic injury, and fluid loss from prolonged vomiting or diarrhea

• May occur rapidly in infants and quickly become life-threatening

• May be delayed in children who then suddenly decompensate

• Common cause of cardiac arrest in infants and children


Signs and Symptoms of Shock

• Rapid (early) or slow (late) weak pulse or absent pulse

• Unequal central and peripheral pulses

• Poor skin perfusion, delayed capillary refill

• Cool, clammy, pale skin

• Rapid respiratory rate (early shock)



Emergency Care for Shock


• Control any bleeding


• Monitor pulse carefully and provide CPR if needed

• Raise legs if spinal or traumatic injury is not suspected

• Keep patient warm but not overheated

• Monitor vital signs frequently while awaiting EMS


Seizures


Causes of Seizures

• High fever

• Epilepsy

• Infections

• Head injuries

• Poisoning

• Low oxygen levels

• Low blood sugar

• Other causes


Seizures

• Potentially life-threatening

• You don’t need to know cause to give care

• Febrile seizures common in children <5 years

• Most will be over by the time you arrive at scene

• After a seizure (except a febrile seizure), child appears sleepy and confused


Assessing Seizures

• Perform standard assessment

• Assess for injuries that may occur

• Gather the history from caretakers:

- Has child had prior seizure(s)?

- Is this child’s usual seizure pattern? How long did it last?

- Does child take seizure medication?

- Could child have ingested any other medication or potential toxins?


Signs and Symptoms of Seizures


• Muscle twitching, convulsions, rigid extremities

• May be brief or prolonged

• Loss of bowel and bladder control


Emergency Care for Seizures


• Place patient on floor and protect patient from environment

• Loosen any constricting clothing, remove eyeglasses

• Ask bystanders (except caretakers) to leave

• Ensure airway remains open

• Never restrain patient

• Don’t put anything in mouth


Emergency Care for Seizures(continued)

• If patient is bluish, ensure airway is open and give ventilations

• After seizure, place an unresponsive patient in recovery position

• Be prepared to suction to maintain airway


• Report assessment findings to additional EMS personnel


Altered Mental Status


Causes of Altered Mental Status

• Low blood sugar

• Poisoning

• Seizures

• Infection

• Head trauma

• Any condition that causes decreased oxygen levels


Assessing Altered Mental Status


• Ask caretakers about any history of diabetes, seizures or recent trauma

• Monitor patient’s vital signs


Signs and Symptoms of Altered Mental Status in an Infant or Child

• Drowsiness

• Confusion, agitation

• Behavior described as unusual by caretakers


Emergency Care for Altered Mental Status


• Place unresponsive patient in recovery position (if no trauma suspected)



Sudden Infant Death Syndrome


Sudden Infant Death Syndrome

• Sudden Infant Death Syndrome (SIDS) is the unexpected, sudden death of a normal, healthy infant during sleep

• Causes not well understood

• Leading cause of death between 1 week and 1 year of age in United States

• Peak incidence occurs at 2-4 months of age


Sudden Infant Death Syndrome(continued)

• More common during winter months and in males

• Not due to external suffocation from blankets or pillows

• Not related to child abuse or vomiting and aspiration of stomach contents


Assessing SIDS

• Perform standard assessment• Complete primary assessment and care for life-threatening

conditions• If infant is still alive, take history and perform secondary

assessment • In addition, ask caretakers about circumstances:

- When was infant put to bed?- When was infant last seen?- What position was infant in when found? - How did infant look when found?- Was there anything unusual in environment?- Infant’s general health recently?


Signs and Symptoms of SIDS

• Cardiac and respiratory arrest

• Skin cyanotic or mottled

• Most commonly discovered in early morning


Emergency Care for SIDS


• Take body substance isolation precautions

• Try to resuscitate infant unless the body is stiff

• Lividity is normal, not sign of abuse

• Comfort, calm and reassure caretakers

• Avoid any comments that might suggest blame to caretakers


Trauma


Trauma

• Common emergency in childhood

• Leading cause of death in children

• Blunt trauma causes the most injuries

• Pattern of injury may be different from that in adults


Common Causes of Trauma

• Motor vehicle crashes

- Unrestrained infants and children have head/neck injuries

- Restrained infants and children have abdominal and lower spine injuries

- Infant and booster seats often improperly fastened


Common Causes of Trauma(continued)

• Being struck by a vehicle while riding a bicycle

• Being struck by a vehicle while walking

• Falls from a height or diving into shallow water

• Burns

• Sports injuries to head and neck

• Child abuse and neglect


Common Types of Injury

• Anatomical differences make certain types of injury more likely

• Head injuries

• Abdominal injuries

• Extremity injuries

• Burns


Assessing Trauma


• Examine responsive child from toe to head

• Suspect certain types of injuries based on MOI

• Smaller amounts of blood loss can result in shock; signs of shock may occur later


Emergency Care for Trauma


• Use jaw thrust to open airway

- Use head tilt–chin lift if unsuccessful

• Suction airway as needed

• Manually stabilize head and neck


Emergency Care for Trauma (continued)

• Manually stabilize extremity injuries

• Treat shock

• Maintain normal body temperature (hypothermia more likely in shock in children)


• Ensure transport as soon as possible


Child Abuse and Neglect


Suspected Child Abuse and Neglect

• Abuse: an intentional improper and excessive action injuring or causing harm

• May include psychological or emotional abuse and sexual abuse

• Neglect: failing to provide basic needs


Who is Abused?

• Any child, although some are more likely to be abused

• Child abuser can come from any geographic, religious, ethnic, occupational, educational or socioeconomic group

• Abuser is usually a caretaker or someone in role of parent

• Most abusers of children were themselves abused as children


Signs and Symptoms of Abuse

• Multiple bruises or burns in various stages of healing

• Injury inconsistent with MOI described by caretakers

• Bite marks


Signs and Symptoms of Abuse (continued)

• Suspicious patterns of injury or marks on skin:

- Cigarette burns

- Whip marks

- Hand prints

- Injuries to genitals, inner thighs or buttocks

- Rope burns


Signs and Symptoms of Abuse(continued)

• Repeated calls to same address

• Unusual burns

- Scalding

- A glove or dip pattern

- Burns inconsistent with history presented

- Untreated burns

• Caretakers inappropriately unconcerned

• Caretakers with uncontrollable anger


Signs and Symptoms of Abuse(continued)

• Conflicting stories

• Child fearful to discuss how injury occurred

• Child’s obvious fear of caretaker

• Obvious or suspected fractures in child younger than 2

• More injuries than are usually seen at same age

• Injuries scattered on many areas of the body


Signs and Symptoms of Neglect

• Lack of adult supervision

• Child appears malnourished

• Clothing inappropriate for environment

• Unsafe living environment

• Signs of drug or alcohol abuse

• Untreated chronic illness (asthmatic with no medications)

• Untreated soft-tissue injuries

• Delayed call for help


Assessing Suspected Abuse or Neglect


• Obtain as much information as possible

• Document all information on patient report


Emergency Care When Abuse is Suspected


• Don’t accuse caretakers in the field

• Treat patient’s injuries appropriately

• Protect child from further abuse, if necessary

• Report objective information to EMS unit


Emergency Care When Abuse is Suspected (continued)

• Save evidence of physical or sexual abuse

• File a report as required by state law and local protocol:

- Remain objective

- Report what you see and hear

- Do not comment on what you think

• Maintain confidentiality about the call


Shaken Baby Syndrome

• Pattern of injury resulting when caretaker shakes infant

• Also occurs in young children

• Infant may have severe internal injuries, including brain or spinal injuries

• Infant may be unresponsive or experiencing seizures


Emergency Care forShaken Baby Syndrome


• Manually stabilize the head and neck


• Ensure transport as soon as possible


Emergency Medical Responder Stress

• Death or serious injury can cause strong emotional reactions and stress

• Stress is likely in instances of serious child abuse or neglect

• Providing care while family members or caretakers are very emotional is stressful


Emergency Medical Responder Stress (continued)

• Don’t react personally to others’ emotions or behavior

• Realize that many patients may die regardless of care provided

• Talk with family and friends

• Seek professional help

• CISM programs are available

© 2011 National Safety Council 21-1 PEDIATRIC PATIENTS LESSON 21.

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