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Pediatrics

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  • 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
  • Broslow tape
  • 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
  • Blow by
  • 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
  • (test question)
  • 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
  • Use D25
  • 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?
  • Transcript

    • 1. Pediatrics
    • 2. General Approach toPediatric Emergencies
    • 3. Communication and Psychological SupportTreatment begins with communication and psychological support.
    • 4. Responding to Patient NeedsThe child’s most common reaction to anemergency is fear of:  Separation  Removal from a family place  Being hurt  Being mutilated or disfigured  The unknown
    • 5. Responding to Parents or Caregivers Communication! One paramedic speaks with the adults. Introduce yourself and appear calm. Be honest and reassuring. Keep parents informed.
    • 6. Growth andDevelopment
    • 7. Newborns First hours after birth Newborn, neonate Assessed with APGAR scoring system
    • 8. 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.
    • 9. 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.
    • 10. Infants Ages 1 to 12 months. Follow movements. Muscle development develops in cephalo-caudal progression. Allow patient to remain in caregiver’s lap.
    • 11. Infants and young childrenshould be allowed to remain in their mothers’ arms.
    • 12. 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.
    • 13. 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.
    • 14. 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.
    • 15. Common Preschooler Illnesses Croup  Ingestion of foreign Asthma bodies Poisoning  Drowning Auto accidents  Epiglottitis Burns  Febrile seizures Child abuse  Meningitis
    • 16. 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.
    • 17. A small toy may calm a child in the 6–10 year age range.
    • 18. Common Illness and Injuries in School-Age Children Drowning  Fractures Auto accidents  Sports injuries Bicycle accidents  Child abuse Falls  Burns
    • 19. 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.
    • 20. Common Adolescent Illness and Injuries Mononucleosis  Drug and alcohol Asthma problems Auto accidents  Suicidal gestures Sports injuries  Sexual abuse
    • 21. The approach to thepediatric patient should be gentle and slow.
    • 22. Anatomy and Physiology
    • 23. Anatomical and PhysiologicalCharacteristics of Infants and Children
    • 24. Anatomical and physiologicalconsiderations in the infant and child.
    • 25. 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.
    • 26. General Approach toPediatric Assessment
    • 27. 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.
    • 28. The basic steps in pediatric assessment.Notice the components and signs in the Pediatric Assessment Triangle.
    • 29. Opening the airway in a child.
    • 30. Head-tilt/chin-lift method.
    • 31. Jaw-thrust method.
    • 32. Assessing the airway.
    • 33. Signs of respiratory distress. Notice the conditions that can be determined by quick observation.
    • 34. Normal Vital Signs: Infants and Children
    • 35. Signs of Increased Respiratory Effort
    • 36. Anticipating Cardiopulmonary Arrest Respiratory rate  Trauma greater than 60  Burns Heart rate greater than 180 or less than  Cyanosis 80 (under 5 years)  Altered level of Heart rate greater consciousness than 180 or less than  Seizures 60 (over 5 years)  Fever with petechiae Respiratory distress
    • 37. Transport Priority Urgent Non-urgent
    • 38. Focused History and Physical Exam
    • 39. 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
    • 40. Physical Exam
    • 41. Focused or Head-to-Toe Exam Pupils Capillary refill Hydration Pulse oximetry
    • 42. Glasgow Coma Scale Scoring Determines Severity GCS 13–15 = Mild GCS 9–12 = Moderate GCS < 8 = Severe
    • 43. Glasgow Coma ScaleModifications for Infants
    • 44. Vital Signs Pulse Respirations Blood pressure (children over 3 years of age)
    • 45. Taking the brachial pulse.
    • 46. Taking the femoral pulse.
    • 47. Pediatric Weights andPound-Kilogram Conversion
    • 48. If available, noninvasive monitoring, including pulse oximetry andtemperature measurement, should be used in prehospital pediatric care.
    • 49. Ongoing Assessment Reassess the patient since conditions can change rapidly. Reassess every 15 minutes in stable patients. Reassess every 5 minutes in unstable patients.
    • 50. General Management of Pediatric Patients
    • 51. Summary of BLS Maneuvers in Infants and Children
    • 52. Delivering abdominal thrusts (a) on a responsive child and (b) on an unresponsive child.
    • 53. Clearing an Infant’s Airway
    • 54. Recognize and assess for choking.Look for breathing difficulty, ineffective cough, and lack of a strong cry.
    • 55. Give up to 5 back blows.
    • 56. Then administer 5 chest thrusts.
    • 57. If the infant becomes unresponsive,perform a tongue-jaw lift and look for a foreign body.
    • 58. 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.
    • 59. Pediatric-size suction catheters.• Top: soft suction catheter.• Bottom: rigid or hard suction catheter.
    • 60. Suction Catheter Sizes for Infants and Children
    • 61. OxygenationAdequate oxygenation is the hallmark of pediatric patient management.
    • 62. 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.
    • 63. Equipment Guidelines According to Age and Weight
    • 64. Inserting an oropharyngeal airway in a child with the use of a tongue blade.
    • 65. 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.
    • 66. 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.
    • 67. In placing a mask on a child, it should fit on the bridge of the nose and cleft of the chin.
    • 68. In Sellick’s maneuver, pressure is placedon the cricoid cartilage, compressing theesophagus, which reduces regurgitationand helps bring the vocal cords into view.
    • 69. Advanced Airway andVentilatory Management
    • 70. Infant/Child Endotracheal Tubes
    • 71. 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.
    • 72. 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.
    • 73. Pediatric Tube Size Formula (Patient’s age in years + 16) 4
    • 74. 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
    • 75. Placement of the laryngoscope.
    • 76. Endotracheal Intubation in the Child
    • 77. Hyperventilate the child.
    • 78. Position the head.
    • 79. Insert the laryngoscope and visualize the airway.
    • 80. Insert the tube andventilate the child.
    • 81. Confirm tube placement.
    • 82. Nasogastric Intubation
    • 83. Nasogastric IntubationIndications: Inability to achieve adequate tidal volume during ventilation due to gastric distention Presence of gastric distention in an unresponsive patient
    • 84. Oxygenate and continue to ventilate, if possible.
    • 85. Measure the NG tube from the tip of the nose, over the ear, to the tip of the xiphoid process.
    • 86. Lubricate the end of the tube. Then pass itgently downward along the nasal floor to the stomach.
    • 87. Auscultate over the epigastrium to confirm correct placement. Listen for bubbling while injecting 10–20 cc of air into the tube.
    • 88. Use suction to aspirate stomach contents.
    • 89. Secure the tube in place.
    • 90. Rapid Sequence Intubation Indicated in pediatric patients when intubation is difficult due to combativeness or clenched teeth. Neuromuscular compliance is gained by the use of a paralytic.
    • 91. CirculationTwo problems lead to cardiopulmonaryarrest in children: Shock Respiratory failure
    • 92. Vascular Access Neck veins Scalp veins Arms Hands Feet Intraosseous infusion
    • 93. Intraosseous Infusion Indications Children less than 6 years of age Existence of shock or cardiac arrest Unresponsive patient Unsuccessful peripheral IV
    • 94. Intraosseous Infusion Contraindications Fracture in the bone chosen for IO Fracture of the pelvis or extremity fracture of bone, proximal to the chosen site
    • 95. Intraosseous administration.
    • 96. Drugs Administered by IO Route Epinephrine Atropine Dopamine Lidocaine Sodium bicarbonate Dobutamine
    • 97. Fluid Administration Accurate fluid dosing in children is crucial!
    • 98. 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.
    • 99. Immobilizing a Patient in a Child Safety Seat
    • 100. One paramedic stabilizes the car seat inan upright position and applies and maintains manual inline stabilization throughout the immobilization process.
    • 101. A second paramedic applies an appropriatelysized cervical collar. If one is not available, improvise using a rolled hand towel.
    • 102. 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.
    • 103. 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.
    • 104. Applying a PediatricImmobilization System
    • 105. Position the patient on the immobilization system.
    • 106. Adjust the color-coded straps to fit the child.
    • 107. Attach the four-point safety system.
    • 108. Fasten the adjustable head-support system.
    • 109. The patient fully immobilized to the system.
    • 110. Move the immobilized patient onto thestretcher and fasten the loops at both ends to connect to the stretcher straps.
    • 111. Emotional support of the infant or child continues during transport.
    • 112. Never delay transport to perform a procedure that can be done en route to the hospital!
    • 113. Specific Medical Emergencies
    • 114. Respiratory Emergencies Respiratory Distress Respiratory Failure Respiratory Arrest
    • 115. Respiratory Emergencies Infections Upper airway distress Croup Epiglottitis Lower airway distress Asthma Bronchiolitis
    • 116. a. Croup andb. Epiglottitis
    • 117. Positioning of the child with epiglottitis. Often there will be excessive drooling.
    • 118. The child with epiglottitis should be administered humidified oxygen andtransported in a comfortable position.
    • 119. The young asthma patient may be making use of a prescribed inhaler to relieve symptoms.
    • 120. Specific Medical Emergencies Shock  Dysrhythmias Congenital heart  Meningitis disease  Gastrointestinal Cardiomyopathy emergencies Neurological  Metabolic emergencies emergencies
    • 121. Causes of Shock Hypothermia Dehydration (vomiting, Diarrhea) Infection Trauma Allergic Reaction
    • 122. Signs and symptoms of shock (hypoperfusion) in a child.
    • 123. Pediatric bradycardia treatment algorhythm.
    • 124. Pediatric asystole and cardiacarrest treatment algorhythm.
    • 125. 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.
    • 126. Poisoning and Toxic Exposure Accidental poisoning is a common childhood emergency. Leading cause of preventable death in children.
    • 127. Some of the poisons commonly ingested by children.
    • 128. Possible indicators of ingested poisoning in children.
    • 129. Trauma Emergencies Falls Motor vehicle crashes Car vs. pedestrian injuries Drowning and near drowning Penetrating injuries Burns Physical abuse
    • 130. Falls are the most common cause of injury in young children.
    • 131. A deploying airbag can propel a child safety seat back into the vehicle’s seat,seriously injuring the child secured in it.
    • 132. In the pediatric trauma victim, use thecombination of jaw-thrust/spine-stabilization maneuver to open the airway.
    • 133. Simultaneous cervical spine immobilization and intubation in a pediatric patient.
    • 134. Specific Injuries Head, face, and neck Chest and abdomen Extremities Burns
    • 135. Signs and symptoms of a fracture in a child who has fallen off a bike.
    • 136. The rule of nines helps estimate the extentof burns in adults and children. Note the modifications for the child.
    • 137. 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.
    • 138. Child Abuse and Neglect
    • 139. The stigmata of child abuse.
    • 140. 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.
    • 141. Burn injury from placing achild’s buttocks in hot water as a punishment.
    • 142. Child neglect from lack ofappropriate medical care.
    • 143. The effects of child abuse,both physical and mental, can last a lifetime.
    • 144. 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
    • 145. Tracheotomy tubes. • Top: Plastic tube • Bottom: metal tube with inner cannula
    • 146. 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

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