Communication and Psychological SupportTreatment begins with communication and psychological support.
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
Responding to Parents or Caregivers Communication! One paramedic speaks with the adults. Introduce yourself and appear calm. Be honest and reassuring. Keep parents informed.
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.
Anatomy and Physiology
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.
General Approach toPediatric Assessment
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.
Opening the airway in a child.
Assessing the airway.
Signs of respiratory distress. Notice the conditions that can be determined by quick observation.
Normal Vital Signs: Infants and Children
Signs of Increased Respiratory Effort
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
Transport Priority Urgent Non-urgent
Focused History and Physical Exam
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
Focused or Head-to-Toe Exam Pupils Capillary refill Hydration Pulse oximetry
Glasgow Coma Scale Scoring Determines Severity GCS 13–15 = Mild GCS 9–12 = Moderate GCS < 8 = Severe
Glasgow Coma ScaleModifications for Infants
Vital Signs Pulse Respirations Blood pressure (children over 3 years of age)
Taking the brachial pulse.
Taking the femoral pulse.
Pediatric Weights andPound-Kilogram Conversion
If available, noninvasive monitoring, including pulse oximetry andtemperature measurement, should be used in prehospital pediatric care.
Ongoing Assessment Reassess the patient since conditions can change rapidly. Reassess every 15 minutes in stable patients. Reassess every 5 minutes in unstable patients.
General Management of Pediatric Patients
Summary of BLS Maneuvers in Infants and Children
Delivering abdominal thrusts (a) on a responsive child and (b) on an unresponsive child.
Clearing an Infant’s Airway
Recognize and assess for choking.Look for breathing difficulty, ineffective cough, and lack of a strong cry.
Give up to 5 back blows.
Then administer 5 chest thrusts.
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.
Advanced Airway andVentilatory Management
Infant/Child Endotracheal Tubes
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
Placement of the laryngoscope.
Endotracheal Intubation in the Child
Hyperventilate the child.
Position the head.
Insert the laryngoscope and visualize the airway.
Insert the tube andventilate the child.
Confirm tube placement.
Nasogastric IntubationIndications: Inability to achieve adequate tidal volume during ventilation due to gastric distention Presence of gastric distention in an unresponsive patient
Oxygenate and continue to ventilate, if possible.
Measure the NG tube from the tip of the nose, over the ear, to the tip of the xiphoid process.
Lubricate the end of the tube. Then pass itgently downward along the nasal floor to the stomach.
Auscultate over the epigastrium to confirm correct placement. Listen for bubbling while injecting 10–20 cc of air into the tube.
Use suction to aspirate stomach contents.
Secure the tube in place.
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.
CirculationTwo problems lead to cardiopulmonaryarrest in children: Shock Respiratory failure
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.
Immobilizing a Patient in a Child Safety Seat
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.
Applying a PediatricImmobilization System
Position the patient on the immobilization system.
Adjust the color-coded straps to fit the child.
Attach the four-point safety system.
Fasten the adjustable head-support system.
The patient fully immobilized to the system.
Move the immobilized patient onto thestretcher and fasten the loops at both ends to connect to the stretcher straps.
Emotional support of the infant or child continues during transport.
Never delay transport to perform a procedure that can be done en route to the hospital!
Signs and symptoms of shock (hypoperfusion) in a child.
Pediatric bradycardia treatment algorhythm.
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.
Child Abuse and Neglect
The stigmata of child abuse.
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