Keep in mind, children are not small adults, they have special considerations and needs. They often can’t tell you what is wrong. And their small size makes IV, ET and immobilization more difficult. In addition, incidents involving children are very stressful for the parents as well as the responders. What are some causes of pediatric deaths? MVA, Burns, Drownings, Suicides and Homicides. #1 cause is head injury, #2 is blunt chest trauma
You must consider pts emotional and physiologic development. Don’t forget parents must give informed consent for treatment!
Parents or caregivers will be your primary source of information. Some older children may be able to give history. Allow them to be apart of treatment decisions.
Often, calls involving children are chaotic. Children detect fear and anxiety from their parents. It is up to you to reduce their anxiety in order to treat them. How do you deal with these calls? Backboarding IVs Oxygen mask
One paramedic speaks with adult, second paramedic focuses on child Some parents may be destraught and interfear with care Be alert for patterns of abuse. In such cases caregiver may try to block care (we will cover this later)
Keep child warm Observe skin color, tone and respitratory activity Tenting or lack of tears while crying may denote dehydration Use a pacifier to calm pt while assessing, check lung sounds first while child is quiet Any illness the involves fever should be agressively worked up since it is difficult to distinguish between minor and severe illnesses.
By 12 months, infants can usually stand or walk on their own Extreme danger of foreign body airwy obstruction Other illnesses and injuries are what? mva, sids, vomiting, diarrhea, dehydration, meningitis, croup, poisonings falls and other household injuries, febrile seizure Hate to be laid on back Cling to mother, father will often do, there allow pt to remain in parents lap
Not only do vitals differ from adults, their bodies are well suited to growth and their organs are healthier and therefore they have a greater ability to compensate for illness or injury. Their tissues are softer and more flexible.
“ assessment from the doorway” Triangle – “sick” child Appearance – Mental Status and muscle tone (response to EMT, interaction with surrondings) Breathing – Quality of cry, sternal retractions, flared nostrils, general respiratory effort Circulation – Skin color, cap refill. AVPU – never shake and infant or child Airway – can you maintain with head positioning and suctioning? Or do you need to intubate Remember, Airway and Resp problems are the most common cause of cardiac arrest in infants and young children
Look for fast or slow resp rate as well as resp effort Slow heart rate is generally indicative of hypoxia and is an ominous sign of impending cardiac arrest The presence of peripheral pulses is a good of end organ perfusion
Children don’t usually suffer sudden cardiac arrest. Rather it’s a progressive deterioration, therefore you need to determine wether the patient is improving or deteriorating
Ask about any chronic illnesses, if the child is under the care of a doctor and what for
Do a toe to head exam for younger pts If unresponsive do complete rapid assessment, if minor perform exam focused on affected area
Cap refill – under 6 sole of foot on infant Hydration – skin turger, tears and saliva, fontanelles Pulse ox – hypothermia or shock will alter readings due to peripheral vasocinstriction
Infants under 4 will grasp objects place in palm
Pulse - Anxiety will increase pulse and resp in child monitor pulse for a full 60 sec BP - Hypotension is a late sign of shock
Continuous O2 sat monitor to guard against cardiopulm arrest
Reasses resp effort, skin color, mental status and pulse ox
Determine if pt airway complete obstruction Remember, you can also use direct laryngoscopy in unresp
Remember Never attempt blind finger sweep
Check pulse – stop if bradycardia ensues
Can also use bulb syringe in infants with deminised LOC and excess secretions
Use only for prolonged resucitation, can cause complications such as soft tissue damage, vomiting, vagus stimuli Children often improve greatly with just the aplication of 100% O2
Visualization of the tube is better
It is very difficult to obtain a straight visual plain into glottis, there fore straight blade is preferred. Narrowest part of airway is at cricoid, not vocal cords A misplaced or missized tube can quickly cause hypoxia and death How do you select the proper tube size? The same size as the patient’s little finger (test question)
Remember, stylet is rarely needed
EOA and PtL can not be used in children, LMA can but does not protect against aspiration
For 2 minutes
Do not attempt if head or face trauma And only if ET tube is alredy in place. Why?
Succinylcholine neuromuscular blocker, paralytic of short duration Also need sedative such as versed, valium Pancurium and vecuronium much longer lasting
Remember, look at the total child, mental status, skin color and temp, resp effort, urine output Venous access and fluid resusitation is the primary treatment after resp correction
1-3 cm below tibal tuberosity Twisting motion until feel pop stands on own Withdraw marrow or free flow of fluid (test question)
Too much can cause heart filure and pulm edema Too little can be ineffective Use buretrol or other fluid limiting device Dose for shock is 20ml/kg while monitoring for signs of improved perfusion (test question)
Remember, cardiopulm arrest is almost always due to resp problem sauch as drowning, choking or smoke inhalation. Airway ventilation and fluid replacement first Epi doses (test question)
VF is much less common in children 2J/kg (test question)
Remember, childs larger head can be vulnerable to cspine inj. Also, may have cord injury without vertibral injury Have parent stay with child to keep calm
Can also use KED upside down
The majority of childhood emergencies involve the respiratory system. Remember the triangle, if a child looks “ill”, must immediately intervene, if a child is alert and talking then everything will be all right. There are three categories of respiratory compromise. Each category quickly progresses to the next so you must be able to recognize he symptoms Distress – increased work of breathing, normal mentation, fast breathing and heartrate, retractions and nasal flaring. Cyanosis improves with oxygenation Failure – respiratory system is not able to meet the demands of the body, lethargoc, slow breathing and heartrate, central cyanosis Arrest – coma, agonal resps and asystole
Infections – Has everyone had chickenpox? Other illnesses include meningitis, pneumonia, septicemia s/s include fever, tachycardia, tachypnea, seizure, stiff neck, dehydration Whenever you find a infant r child in resp arrest, assume complete upper airway obstruction until proven otherwise Croup – is a viral infection which causes subglotic edema.occurs in children 6 months to 4 years. Barking cough. Stridor Treatment is humidified o2, cool air or humid bathroom may help child. In severe cases, can admin acemic epi and steroids (test question) Epigglottis – bacterial, 3 to 7 years old, sore throat, dyspnea, fever, drooling. Give humidified o2, et is contraindicated unless complete obstruction. Consider needle cric Status Asthmaticus – is a prolonged asthma attack which cannot be brokn with epinephrine (test question) Bronchiolitis – not bronchitis, s/s similar to asthma, but less than 2 years, spreads through day care Albuterol dosage – 0.03 ml/kg
Congenital – cyanic spells with dyspnea Cardiomyopathy – disease or dysfunction of heart muscle, chf, treatment is supportive Neurologic – seizures, status epilep refers to two or more seizures without a period of consciousness. (test question) What are causes?can give valium rectally Meningitis – s/s headache, seizures, stiff neck, bulging fontanelles and pinpoint rash (test question) Gastro – gastroenteritis, dehydration due to vomiting, fluid bolus, what is dose?
Childs blood vessels constrict ver efficiently but they decompensate quickly Slight increase in heart rate is first sign
Dysrythmias in children are uncommon Tachycadias such as svt and vtach are even more rare. Usually caused by congenital defect can be post resuscitation of drowning
Be alert for new onset diabetes
Larger head causes nek injuries Burns – protect airway from swelling
Also rule of palms 1% Note that children and infants who are burned are more likely to suffer more significant fluid loss than adults because Their body surface area is larger in proportion to their body volume (test question)
Occurs most often in fall and winter months. More prevelant in low birth weight, young mothers, and mothers without prenatal care. May have had mild upper resp infection prior. Place infant on back or side to sleep. Take out blankets and soft bedding, do not smoke around child and do not over heat. Undertak aggressiv care to assure to family that everything possibe is being done. Have someone assigned to the parents to explain everything and always use the baby’s name.
Remember in NYS, EMTs are now mandated reporters. We talked about this subject early in the course so I won’t spend much time. Types of abuse include, psychological, physical, sexual and neglect
Suspect abuse if multiple injuries in different stages of healing, especially burns and bruises injuries on scattered areas of body rns or bruises in patterns suggestive of abuse intra obd trauma any injury that does not fit description of cause given vague parental accounts or that change accusations that the child injured himself intentionaly delay in seeking help child dressed inappropriately
Suspect neglect if extreme malnutrition multiple insect bites long standing skin infections extreme lack of cleanliness verbl or socil skills far belo norm for age lack of appropriate medical care
Trach tube – most common problem is they need suction of mucous plug, use a little steril water to losen first Apnea monitor – ped cpr Ventilator – power goes out Feeding tube – don’t lay down, if obstructed may back up into esophagous cause aspirtion Has any one had experience with special need child?
Newborns First hours after birth Newborn, neonate Assessed with APGAR scoring system
Neonates Birth to one month. Tend to lose 10% of birth weight, but regain in 10 days. Development centers on reflexes. Personality begins to form. Mother, occasionally father, can comfort child.
Neonates, continued Common illnesses include jaundice, vomiting, and respiratory distress. Do not develop fever with minor illness. Allow patient to remain in caregiver’s lap.
Infants Ages 1 to 12 months. Follow movements. Muscle development develops in cephalo-caudal progression. Allow patient to remain in caregiver’s lap.
Infants and young childrenshould be allowed to remain in their mothers’ arms.
Toddlers Ages 1 to 3 years. Great strides in motor development. May stray from parents more frequently. Parents are the only ones who can comfort them. Language development begins. Approach child slowly.
Toddlers, continued Examine from head-to-toe. Avoid asking “yes” or “no” questions. Allow child to hold a favorite blanket or item. Tell child if something will hurt.
Preschoolers Ages 3 to 5 years. Increase in fine and gross motor skills. Children know how to talk. Fear mutilation. Seek comfort and support from within home. Distorted sense of time.
Common Preschooler Illnesses Croup Ingestion of foreign Asthma bodies Poisoning Drowning Auto accidents Epiglottitis Burns Febrile seizures Child abuse Meningitis
School-Age Children Ages 6–12 years. Active and carefree age group. Growth spurts are common. Give this age group responsibility of providing history. Respect modesty.
A small toy may calm a child in the 6–10 year age range.
Common Illness and Injuries in School-Age Children Drowning Fractures Auto accidents Sports injuries Bicycle accidents Child abuse Falls Burns
Adolescents Ages 13 to 18. Begins with puberty, which is very child- specific; are very “body conscious.” May consider themselves “grown up.” Desire to be liked and included by peers. Are generally good historians. Relationships with parents may be strained.
Common Adolescent Illness and Injuries Mononucleosis Drug and alcohol Asthma problems Auto accidents Suicidal gestures Sports injuries Sexual abuse
The approach to thepediatric patient should be gentle and slow.
Anatomical and PhysiologicalCharacteristics of Infants and Children
Anatomical and physiologicalconsiderations in the infant and child.
a. In the supine position, an infant’s or child’s larger head tips forward, causing airway obstruction.b. Placing padding under the patient’s back and shoulders will bring the airway to a neutral or slightly extended position.
Scene Size-Up Conduct a quick scene size-up. Take BSI precautions. Look for clues to mechanism of injury or nature of illness. Allow child time to adjust to you before approaching. Speak softly, simply, at eye level.
The basic steps in pediatric assessment.Notice the components and signs in the Pediatric Assessment Triangle.
History Nature of illness/injury Length of time ill or injured Presence of fever Effects of illness/injury on behavior Bowel/urine habits Presence of vomiting/diarrhea Frequency of urination
If the infant becomes unresponsive,perform a tongue-jaw lift and look for a foreign body.
Suctioning Decrease suction pressure to less than 100 mm/Hg in infants. Avoid excessive suctioning time—less than 15 seconds per attempt. Avoid stimulation of the vagus nerve. Check the pulse frequently.
Pediatric-size suction catheters.• Top: soft suction catheter.• Bottom: rigid or hard suction catheter.
Suction Catheter Sizes for Infants and Children
OxygenationAdequate oxygenation is the hallmark of pediatric patient management.
To overcome a child’s fear of thenon-rebreather mask, try it on yourself or have the parent try it on before attempting to place it on the child.
Equipment Guidelines According to Age and Weight
Inserting an oropharyngeal airway in a child with the use of a tongue blade.
a. In an adult, the airway is inserted with the tip pointing to the roof of the mouth,then rotated into position. b. In an infantor small child, the airway is inserted with the tip pointing toward the tongue andpharynx, in the same position it will be in after insertion.
Ventilation Avoid excessive bag pressure and volume. Obtain chest rise and fall. Allow time for exhalation. Flow-restricted, oxygen-powered devices are contraindicated. Do not use BVMs with pop-off valves. Apply cricoid pressure. Avoid hyperextension of the neck.
In placing a mask on a child, it should fit on the bridge of the nose and cleft of the chin.
In Sellick’s maneuver, pressure is placedon the cricoid cartilage, compressing theesophagus, which reduces regurgitationand helps bring the vocal cords into view.
The Pediatric Airway A straight blade is preferred for greater displacement of the tongue. The pediatric airway narrows at the cricoid cartilage. Uncuffed tubes should be used in children under 8 years of age. Intubation is likely to cause a vagal response in children.
Pediatric Endotracheal Tube Size Use a resuscitation tape that estimates ET tube size based on height. Estimate the correct diameter, based on the child’s little finger.
Pediatric Tube Size Formula (Patient’s age in years + 16) 4
Indications Need for prolonged artificial ventilation Inadequate ventilatory support with a BVM Cardiac or respiratory arrest Control of an airway in a patient without a cough or gag reflex Providing a route for drug administration Access to the airway for suctioning
Fluid Administration Accurate fluid dosing in children is crucial!
Electrical Therapy Initial dose is 2 joules per kilogram of body weight. If unsuccessful, increase to 4 joules per kilogram. If still unsuccessful, focus on correcting hypoxia and acidosis. Transport to a pediatric critical care unit, if possible.
One paramedic stabilizes the car seat inan upright position and applies and maintains manual inline stabilization throughout the immobilization process.
A second paramedic applies an appropriatelysized cervical collar. If one is not available, improvise using a rolled hand towel.
The second paramedic places a smallblanket or towel on the child’s lap, then uses straps or wide tape to secure the chest and pelvic area to the seat.
The second paramedic places towel rolls on both sides ofthe child’s head to fill voids between the head and seat.He then tapes the head into place, taping over the chin,which would put pressure on the neck. The patient andseat can be carried to the ambulance and strapped to the stretcher, with the stretcher head raised.
Pediatric asystole and cardiacarrest treatment algorhythm.
Many diabetic children have home glucometers to test their blood glucose levels. Older children know what the readings mean and will be curious about any blood glucose testing device that you may use.
Poisoning and Toxic Exposure Accidental poisoning is a common childhood emergency. Leading cause of preventable death in children.
Some of the poisons commonly ingested by children.
Possible indicators of ingested poisoning in children.
Trauma Emergencies Falls Motor vehicle crashes Car vs. pedestrian injuries Drowning and near drowning Penetrating injuries Burns Physical abuse
Falls are the most common cause of injury in young children.
A deploying airbag can propel a child safety seat back into the vehicle’s seat,seriously injuring the child secured in it.
In the pediatric trauma victim, use thecombination of jaw-thrust/spine-stabilization maneuver to open the airway.
Simultaneous cervical spine immobilization and intubation in a pediatric patient.
Specific Injuries Head, face, and neck Chest and abdomen Extremities Burns
Signs and symptoms of a fracture in a child who has fallen off a bike.
The rule of nines helps estimate the extentof burns in adults and children. Note the modifications for the child.
Sudden Infant Death Syndrome (SIDS) SIDS is the sudden death of an infant during the first year of life from an illness of unknown etiology.
An abused child. Note the marks on the legs associated with beatings with anelectric wire. The burns on the buttocks are from submersion in hot water.
Burn injury from placing achild’s buttocks in hot water as a punishment.
Child neglect from lack ofappropriate medical care.
The effects of child abuse,both physical and mental, can last a lifetime.
Infants and Children with Special Needs Common home-care devices Tracheostomy tubes Apnea monitors Home artificial ventilators Central intravenous lines Gastric feeding and gastrostomy tubes Shunts
Tracheotomy tubes. • Top: Plastic tube • Bottom: metal tube with inner cannula
Summary Roles of the Paramedic in Pediatric Care Growth and Development Assessment Airway Adjuncts and Intravenous Access Medical Emergencies Traumatic Injuries Child Abuse and Neglect