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Pediatric Prehospital Care Course

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  • Instructor Note: While this lesson is an integral portion of the program, it can also be used independently for review. Please distribute handouts: Rapid First Impression of Pediatric Respiratory Emergencies, CUPS Assessment for Pediatric Respiratory Emergencies, and Assessment Findings for Pediatric Respiratory Emergencies before the start of this lesson. Respiratory problems arising from medical emergencies and trauma are the most common cause of death in children. Early recognition and treatment of respiratory problems by EMTs can greatly improve the outcome and prevent worsening of the child’s condition. In the last two lessons, the steps of rapid first impression and initial assessment have been discussed and explained. In this lesson, these principles will be applied to the management of respiratory problems. These management decisions should be based upon the seriousness of the child’s condition, regardless of the cause.
  • Instructor Note: Some students may be confused about this because they have heard that oxygen has caused blindness in newborns or lung tissue damage in children. The truth is that for in-hospital, long term (i.e., more than 24 hours) care, continuous delivery of high concentration oxygen may be inappropriate. However, the prehospital setting is a totally different situation. High concentration oxygen, in the prehospital setting is known to be life saving for children and has absolutely no contraindications. Demand valve devices are not used for children because they operate at excessive pressures and those pressures can be difficult or impossible to control. The lab skills included in this lesson are ventilation with BVM and airway adjuncts.
  • Three categories of respiratory emergencies; distress, failure and arrest, are commonly used to describe the severity of the respiratory emergency. Each of these categories represent a general group of physical findings, however, not all findings must be present in all cases. For instance, a child in respiratory distress may not be agitated or restless, but be calm and alert.
  • Patients with signs of respiratory distress are alert and sometimes agitated. They generally have good muscle tone, pink or pale central skin color, and increased breathing effort. EMTs may note partial airway obstruction, a fast respiratory rate, and wheezing or stridor. Chest rise may be normal or shallow. Lack of oxygen is the primary problem in respiratory distress. Other than ensuring an open airway, oxygen delivery is one of the most important interventions EMTs can provide. In many cases, supplemental high concentration oxygen may be the only intervention necessary to stabilize the patient long enough to reach the hospital. In addition to breathing harder and faster, children in respiratory distress will frequently have a faster than normal heart rate. The heart beats faster in order to increase the oxygen supply to the blood. As respiratory distress becomes more severe, the heart rate will continue to climb until the oxygen supply becomes too scarce to support this increased heart rate.
  • Keep the child in the position he/she finds most comfortable for breathing. Never force a child with respiratory distress to lie down. Deliver high-concentration oxygen using a nonrebreather mask. Sizing is critical. For good oxygen delivery, the mask must fit the face, with the bottom of the mask resting on the crease of the chin when the top of the mask is placed over the bridge of the nose. Adjust the oxygen flow so that the bag remains inflated when the child breathes in. Children in respiratory distress can respond with increased agitation when EMTs attempt to place the nonrebreather mask. EMTs might try holding the mask near the face instead of against it to avoid agitating the child. If the child does not tolerate this, try simply aiming oxygen tubing near the child's nose. Another possibility is to place the oxygen tubing in a paper cup and let the parents hold the cup while asking the child to pretend to drink from it.
  • Humidification of oxygen is a step that is often overlooked in the prehospital setting. Providing high concentration oxygen should always be done as soon as possible, and therefore, at the scene of the call, it may not be possible to humidify the oxygen being provided. However, once in the ambulance and underway to the hospital, adding humidification to the oxygen will prevent irritation and drying of the mucous membranes.
  • Children in respiratory failure appear ill. They will appear agitated or sleepy during the first impression, with pale, mottled, or blue skin tones. They will have decreased muscle tone and may be unable to sit up without help. The breathing rate is usually very fast, although there may be periods of slowing. EMTs may note signs of increased breathing effort, such as nasal flaring, retractions, or head bobbing, with occasional periods of decreased effort, indicated by shallow chest rise. Since the onset of the respiratory problem, the child has been using ever increasing amounts of energy in order to breathe harder and faster. The increased effort and rate of breathing was required to maintain his blood oxygen level. Also, his heart rate increased in order to pump blood oxygen at a faster rate. The child is now becoming tired from this additional effort and is showing signs of fatigue. Because he is physically unable to continue his extra effort of breathing, his blood oxygen level is dropping. His heart rate will be very fast, until it is also too deprived of blood oxygen to continue beating rapidly. As a result, he has a change in mental state, slackened muscle tone, and periods of slowed respirations. The heart rate will also slow down. As fatigue becomes more severe, the child will become sleepy, limp, chest rise will become shallow and the heart rate will slow even more.
  • Give high-concentration oxygen. Prepare for transport. Deliver high-concentration oxygen using a non-rebreather mask. Remember to properly size the mask. As discussed in the treatment of respiratory distress, children can respond with increased agitation when EMTs attempt to place the non-rebreather mask. EMTs might try holding the mask near the face instead of against it to avoid agitating the child. If the child does not tolerate this, try simply aiming oxygen tubing near the child's nose. Another possibility is to place the oxygen tubing in a paper cup and let the parents hold the cup while asking the child to pretend to drink from it. Assess for signs of improvement. A child who is responding to the EMTs‘ interventions will show improved muscle tone. A sleepy child should become more alert. Respiratory effort should decrease and skin color should improve.
  • Assure chest rise: Look, listen, and feel for chest rise and air movement. If the airway is blocked with vomit, secretions, small foreign particles, or blood, EMTs should provide gentle suctioning. Since the patient will probably have an active gag reflex, they must carefully control the tip of the device to suction shallowly. After suctioning, EMTs should check for signs of improvement, such as pink color returning to the skin or improved mental status. These improvements should occur almost immediately. If there is no significant improvement, EMTs should reassess the airway, assure that it is open and then, begin ventilations.
  • Once EMTs have positioned and suctioned the airway and provided high-concentration oxygen, they should prepare the child for transport. If airway positioning, suctioning, nasal airway, and high-concentration oxygen fail to maintain adequate ventilation, EMTs should begin assisted ventilation as described for children in respiratory arrest.
  • If necessary, EMTs may place a nasopharyngeal airway to help keep the air passage between the nose and the back of the throat open for suctioning or oxygen delivery. Nasal airways can be used in conscious children who cannot maintain an open airway. They should not be used in children with facial trauma or head injuries. An oropharyneal airway is contraindicated in a responsive child, and therefore, cannot be considered for the child in respiratory failure. Do not use this airway in an agitated child as it will increase agitation. Increased agitation can easily worsen respiratory distress. With facial or head trauma, the nasopharyngeal airway is not used due to the possibility of internal injuries. Introducing the nasopharyngeal airway into injured areas may cause additional damage to those structures.
  • Due to the prominence of the adenoidal tissue in these children, nasopharyngeal airways must be considered as adjunct devices only. It may be advisable to call for ALS if additional airway control is needed.
  • It is important to use a correctly sized nasal airway. EMTs should select an airway that is about the same thickness as the patient's little finger. The length should extend from the nostril to the tip of the earlobe. Apply a water-soluble lubricant and slowly insert the airway into the child's nostril, holding the airway at a right angle to the face. The correct insertion distance is from the nose to the earlobe . During insertion, keep the bevel toward the middle of the nose. Direct the airway straight back along the floor of the nasal passage. Suction as necessary to clear secretions.
  • Children experiencing respiratory arrest will be unresponsive and limp, with a blue color around the lips and slow or absent respiratory rate and effort. Respiratory arrest is an end process of respiratory failure. The fatigue which led the child from respiratory distress to failure has now become exhaustion. This leaves the child unable to make any sustained effort at breathing. While there may be some slight effort, or an occasional breath, respiratory arrest is present. The periods of apnea (without breathing) will lengthen until all respiratory effort ceases. These children require airway positioning including the head tilt and chin lift or modified jaw thrust, airway clearing with suction, if secretions or vomitus block the airway, and ventilation with a bag-valve-mask. At the same time, the heart rate is slowing because the heart muscle becomes starved for oxygen. The heart cannot pump effectively or quickly without oxygen. Once the heart rate drops below 60 beats per minute, chest compressions are initiated.
  • Instructor Note: The scenario is set at a carnival so that there is no one obvious source of the respiratory distress. In this scenario, the parents are not present. This limits the ability of the students to ascertain past medical history and medications. By limiting the available history and providing an environment where many contributing factors may play a role in causing the respiratory distress, the intent is to encourage the students to follow through the steps of Rapid First Impression (RFI), make a decision about urgent status and treatment, initiate transport and conduct the initial assessment.
  • The steps of the Rapid First Impression involve assessing appearance, including mental state, body position and skin color, followed by breathing and circulation. His appearance: His mental state is a form of anxiety, as he is not interacting with the concerned adults around him, but concentrating on his own breathing effort. He is alert enough to keep himself in an upright position, but his mental state is not normal. Body position is stiff, with his position maintained by leaning forward (tripod position) and tilting back his head (sniffing position). This is a combination of body positions commonly seen in children who are experiencing respiratory distress. By assuming this posture, the child is moving the work of holding himself upright from his chest muscles to his arms. This, then, allows the child to use his chest muscles only for breathing. Simultaneously, he has tilted his head back into the sniffing position. This position allows him to open his airway as much as possible, again, a sign of respiratory distress. His skin is pale, which indicates that his blood oxygen is low, but is being maintained at a level adequate for him to maintain his upright position.
  • Although you are not yet able to determine the breathing rate, there are signs of extra effort of breathing in that you can see his neck muscles are being used to move air. In the rapid first assessment, circulation is not yet ascertainable beyond the skin, which is pale. His condition is urgent, as there are multiple findings that are not normal; mental state, body position, skin color and extra effort of breathing. This child has severe respiratory distress. Remember that, although we are using three categories of respiratory emergencies, there are degrees of respiratory distress from mild to moderate or severe. He is not, as yet, in respiratory failure, as he is maintaining his oxygenation.
  • How agitation affects breathing: A child with respiratory problems who is agitated or frightened by EMTs will begin breathing harder and faster. This leads to increased resistance in the air passages, which in turn worsens breathing problems. EMTs may understand this concept better if they think about breathing through a narrow paper straw. When they breathe at a normal rate, air moves easily through the straw. If they exercise vigorously until they’re breathing hard, then try again, the straw will tend to collapse. A similar principle is at work when children are breathing hard through narrow air passages. Because the child is breathing harder and faster, he will require more oxygen to support his breathing, but because he is in respiratory distress already, he is unable to get this additional oxygen. As a result, the child will develop more severe respiratory distress or even begin to experience respiratory failure, if agitated. EMTs who spend a few moments to assure the child of their ability to help and explain their intended actions prior to performing them can successfully avoid unnecessary agitation.
  • Whenever the patient is a child, there is at least one other person to be considered; the parent or caregiver. The role of the second EMT is to reassure these adults, obtain information about the child and to communicate with them about the treatment and transportation of the child. Gathering information about the circumstances that brought about this condition is also helpful. The child may not be able to adequately explain what occurred, while an adult is more likely to possess and articulate this valuable information.
  • The airway is open, as the child can speak and no stridor or gurgling is heard. Continue with next slide.
  • Although the initial assessment will reveal more complete information about the patient’s problem, it is clear from the rapid first impression that the child has an urgent respiratory problem. There is no reason to delay oxygen administration. Prepare the child for your impending actions: “I’m going to put a mask on your face to help your breathing. It won’t hurt, but it will feel tight on top of your nose and cheeks.” As soon as oxygen is being provided, preparation for transportation should be made. Explain this to the child. Arrange for one of the adults to accompany him. The child should be moved to the transport vehicle as smoothly and comfortably as possible. This child should be placed on a wheeled stretcher or chair device and kept as upright as possible. Initial assessment should then be performed.
  • Humidify the oxygen. Now is the time for the initial assessment.
  • The child is able to speak, although only in short sentences. Therefore, he is moving some air, however, the volume is insufficient to allow him to speak normally. The child is using his neck and abdominal muscles to move air. These are signs of extra effort of breathing. The absence of gurgling and stridor indicate that the source of the problem is not in the upper airway. You can now confirm that the airway is open, without the potential for upper airway compromise. You have also discovered additional signs of respiratory distress (speaking in short sentences, abdominal muscle use). Humidified, high concentration oxygen by non-rebreather face mask is already in place. The next task is to perform the initial assessment of breathing.
  • Continue with the next slide.
  • The chest wall has equal movement, depth and rhythm. This suggests that there is no localized problem such as pneumothorax or chest wall injury. The presence of whistles over the lungs describes wheezes. Wheezes are the sound heard when air is trapped by spasm and mucous in the larger air passageways. These sounds are pronounced on expiration, which is also characteristic of wheezes. The absence of whistles over the trachea also confirms that the problem is in the lower airways in the lungs and not the upper airway. The respiratory rate is 32/min. This rate is slightly above the normal range for a child of this age, however, consider that the rate is being sustained with a lot of extra work. It is not always possible for a child to greatly raise his breathing rate due to the extreme effort and additional time each breath requires. In this case, the extra work is pronounced during expiration. In the absence of respiratory distress, breathing out is normally a passive process, requiring very little effort. In this child, however, breathing out is hard work and requires extra time. The pink skin tone is a sign that the child is responding to the high concentration oxygen administration. Although he remains in respiratory distress, his blood oxygen level is improving. Continue the oxygen treatment and assess circulation.
  • The skin is pale, which indicates less blood oxygen is reaching the skin either because the heart is not pumping well enough or because the blood being pumped by the heart does not contain sufficient oxygen. In this assessment, respiratory distress is the cause of low blood oxygen level. The strength of central and peripheral pulses is nearly equal, suggesting that the child is not experiencing a problem with delivery of the blood, but with the lack of oxygen the blood contains. The normal capillary refill time, the warmth of the skin also support that the pumping action of the heart is not the cause. The heart rate of 120/min. is a high-normal value for this child. It is particularly high when you consider that the child is essentially at rest; sitting quietly, in a position of comfort. This increased heart rate is occurring because of the respiratory distress. The treatment indicated is to continue high concentration oxygen and reassessment for response to the oxygen treatment. Assess for disability and determine the CUPS assessment.
  • At this time the child is able to speak and is alert according to the AVPU scale because he is oriented to person, place and time. Compare this finding with that of the RFI where he was not interacting with the adults around him because he was concentrating on his breathing efforts. What has occurred to cause this improvement? His mental state has improved as a result of the high concentration oxygen he has been receiving. This improvement indicates that blood oxygen levels are rising. The treatment indicated is continuation of the high concentration oxygen. His CUPS status is P, potentially unstable. Initially, when first encountered, the patient’s CUPS would have been U as he had compromised breathing as demonstrated by his change in mental state, body position and muscle tone and pale skin color. At this time, both his skin color and mental state are improving, although he continues to have respiratory distress, therefore his status is P. Treatment now is to obtain a focused history, repeat the initial assessment, looking for further signs of improvement, and continued high concentration oxygen.
  • The child is unable to provide past medical history, however, he gives some information about the events leading up to his respiratory distress.. Ask the class to discuss possibilities for the cause of the problem. Environment Was he allergic to the pony or come into contact with an unknown allergen? Stress: Did the “scary” spinning ride provoke the problem by inducing a stressful situation from which he could not immediately escape? Without more information, it is impossible to declare absolutely the cause of this problem, however, discuss with the class that the course of treatment would be the same, despite the cause, because the treatment decisions were based upon the child’s condition.
  • Croup and epiglottitis are upper airway illnesses that are assessed and treated according to the child’s condition. However, they are discussed in this lesson because EMTs treating a child who presents with either problem need to be aware of the special concerns involved in the care of these children: Put nothing in the mouth. Avoid agitating these children. Agitation will cause further airway obstruction. In the event of respiratory arrest, these children can be ventilated with a BVM, but airway adjuncts should not be used due to the irritation they can cause.
  • Foreign body obstruction happens most frequently in children younger than four years. In complete airway obstruction, the patient cannot cough, cry, speak, or breathe, and quickly turns blue, losing consciousness. Begin foreign body maneuvers using back blows and chest thrusts in infants or abdominal thrusts in older children. If the foreign body can be clearly seen in the child’s mouth at any point during back blows or chest thrusts, remove it. Repeat attempts at assisted ventilation following foreign body maneuvers. More often, the obstruction is cleared prior to the arrival of EMTs. The child appears fine and it seems as though the emergency has passed. What EMTs cannot know is how irritated the airway tissues may have become at the time of the obstruction. Hours may pass before the tissue irritation develops swelling and airway obstruction. The other concern is that there may be a fragment of the foreign body left in the airway. That fragment can cause another episode of obstruction. Any child who experiences an airway obstruction, even when the child appears to be in good condition, deserves transport to the hospital for further evaluation.
  • Recognizing upper airway disease and supporting breathing efforts are critical tasks for EMTs when faced with this situation. While croup and epiglottitis are very different diseases, they often present with similar signs. Therefore, attempting to discern the precise diagnosis is not important. In fact, it may not be possible for physicians to precisely diagnose the problem without extensive testing with in-hospital equipment.
  • Croup: A viral infection that generally presents with a low-grade fever of 100.5 to 102 degrees Fahrenheit. The child will have a “seal-bark” cough. Stridor frequently will be present, especially if the child is agitated. Onset is gradual and symptoms worsen at night. The disease is more common in children two to four years old.
  • Epiglottitis: A bacterial infection that generally presents with a higher fever ranging from 102 to 104 degrees Fahrenheit. The child may drool due to difficulty swallowing. Stridor will be present even if the child is resting. Onset is rapid and the child often assumes a tripod position to maximize breathing comfort. Epiglottitis is more likely to occur in children four to six years old. The disease is becoming less common due to vaccination against the H. influenza B bacterium that causes it.
  • The epiglottis is a small flap of tissue at the top of the trachea that must be open in order for air to enter or leave the lower airways. When the epiglottis is swollen, the swelling will partially obstruct the airway, which produces stridor. As swelling increases, the severity of airway obstruction increases, and the child’s condition worsens. Assess and treat the child according to the RFI and Initial Assessment steps. Treatment should be based upon the severity of the child’s condition. Avoid placing anything in the patient’s mouth as the swollen tissue can be easily irritated. The response to the irritation is to produce additional swelling and thereby, increase airway obstruction.
  • Pneumonia: Patients will have fever, decreased activity levels, and poor appetite. There may be a cough, decreased breath sounds, or possibly absent breath sounds. There may also be chest pain while coughing or breathing in. Children of any age can be affected, developing mild to severe respiratory distress. More severe cases may lead to septic shock.
  • Asthma: In most cases, the child or parents will be aware that this disease is present and will report it to the EMTs when asked. In asthma, the small air passages of the lungs can go into spasm and narrow, leading to respiratory distress. Assessment findings include wheezing or decreased breath sounds. Severe attacks can be fatal. Wheezes are not always heard with children who are experiencing a severe episode of asthma. This is because the airways can become very narrow and as a result, be completely blocked by mucous, causing a plugging of the airways. Wheezes are only heard if air is moving through the passages. The absence of wheezes in a child with respiratory failure caused by asthma is an alarming finding.
  • Humidification of oxygen is important as water vapor will aid in lubricating the lower airways, and may help to thin mucous. In New York State, regions are developing protocols for the administration of albuterol. Discussion regarding indications, dosage and medical control for this administration varies. Please consult your local protocol and discuss these parameters with the class. Wheezes will change in pitch and loudness with treatment. High pitched wheezes will often become lower pitched and more diffuse after albuterol treatment. This indicates that a larger volume of air is moving through the lungs.
  • Bronchiolitis: A viral infection in which the small air passages narrow due to inflammation. Bronchiolitis causes many of the same symptoms as asthma. The disease occurs more commonly in winter and usually affects children younger than eighteen months.
  • An ALTE is characterized by absence of breathing for longer than twenty seconds, frequently accompanied by one or more of the following: a bluish color to the lips, face, and chest; choking or gagging; unresponsiveness; limp muscle tone. The baby frequently recovers normal appearance and assessment findings by the time EMTs arrive. This infant requires transportation and evaluation at the hospital.

Pediatric Prehospital Care Course Pediatric Prehospital Care Course Presentation Transcript

  • Respiratory Emergencies Lesson 4
  • Provide Oxygen First
    • Every child with
    • significant trauma
    • or
    • respiratory emergency
    • NEEDS
    • OXYGEN
    • ASAP
    • The child’s condition will dictate which delivery device to use:
      • Bag-Valve-Mask (BVM)
      • Non-rebreather face mask
      • Blow-by via oxygen tubing
    • Respiratory problems are described by the severity of the child’s condition:
    • Respiratory Distress
    • Respiratory Failure
    • Respiratory Arrest
  • Respiratory Distress
    • A child able to maintain adequate oxygenation by
      • using extra effort to move air
      • increasing the breathing rate
    • is in respiratory distress. The degree of distress can be mild, moderate or severe, and is often accompanied by increased heart rate (tachycardia).
  • Treatment of Respiratory Distress
    • Keep the child in a position of comfort.
    • Avoid agitating the child.
    • Provide high concentration oxygen by
    • non-rebreather face mask.
      • If not tolerated, provide blow by oxygen.
  •  
  • Oxygen should always be humidified as soon as possible.
  • Respiratory Failure
    • A child who, despite extra effort and increased breathing rate, is unable to maintain adequate oxygenation or who has poor oxygenation is in respiratory failure.
    • Increased respiratory rate and effort, as well as tachycardia will decline as respiratory failure worsens.
  • Respiratory Failure- Sitting Child
    • Assist the child who is able to sit up into the position most comfortable for breathing.
    • Give high concentration oxygen by non-rebreather face mask.
    • Monitor child for response to oxygen or worsening respiratory failure.
    • Transport ASAP.
  • Respiratory Failure Treatment Child Unable to Sit
    • Open the airway using head tilt - chin lift or modified jaw thrust.
    • Clear the mouth and gently suction visible vomit or secretions.
    • Nasopharyngeal airway, if needed.
    • Provide high concentration oxygen by non-rebreather face mask.
  • Respiratory Failure Treatment Child Unable to Sit
    • If there is no improvement with positioning, airway opening, suctioning and oxygen:
    • Ventilate the child at a rate of 20/min. using a bag-valve-mask, reservoir and high concentration oxygen.
    • Initiate transport .
  •  
  • Nasopharyngeal Airway
    • A child with respiratory failure who is unable to sit and whose airway cannot be kept clear by positioning and suctioning may require a nasopharyngeal airway.
    • Contraindicated by
      • agitation
      • facial or head trauma
  • Nasopharyngeal Airway Caution
    • Children of school age and younger have prominent and delicate adenoidal tissue in their airways.
    • These tissues can be torn, causing bleeding into the airway.
    • If any resistance is met during insertion, stop.
    • Never force a nasopharyngeal airway.
    • Select the correct size:
      • Length - tip of the nose to the earlobe.
      • Diameter - about that of the pinky finger.
    • Lubricate with water soluble jelly and insert gently with bevel facing the nasal septum.
  •  
  • Respiratory Arrest
    • A child who makes no or slight breathing effort is in respiratory arrest.
    • Respiratory arrest is accompanied by severe bradycardia or cardiac arrest.
      • You are called to a local carnival for a “sick child”. There you find a six year old boy sitting upright on a crate, leaning forward on his arms. His head is tilted upward, and while there are concerned adults around him, he does not appear to be talking with them. Instead, he seems to be focused on his breathing. You can see, even from several yards away, that he is using his neck muscles to breathe. His face appears pale.
      • Using the rapid first impression, what assessment can you make?
    • Assess his appearance:
      • Mental state
      • Muscle tone and body position
      • Skin
    • Continue RFI assessment:
    • Breathing
      • Effort
    • Circulation
    • Is his condition urgent or non-urgent ?
    • What is the severity of the respiratory
    • emergency?
    • What are your first actions?
    • One EMT should position him/herself at the child’s eye level, speak calmly and introduce the responders.
    • The child’s condition is urgent. Therefore, transportation should be initiated quickly. However, it is essential to avoid agitating this child. Take a moment to explain who you are and what you intend to do before you touch him.
    • A second EMT should speak with the adults to gather information about what happened to the patient.
    • The adults in the group are teachers and parents who are escorting a first grade class on an outing. The patient’s parents are not among them. One of the adults tells you that “he seemed fine” until about 20 minutes ago, when he told her that he couldn’t breathe.
    • After introducing yourself and explaining that you are there to help, the child tells you “I . . . can’t . . . breathe.”
    • You hear no stridor or gurgling noises.
    • What does this indicate about the child?
    • What is your next action?
    • Explain to the child what you are going to do and then do it.
    • Provide high concentration oxygen by non-rebreather mask, without delay.
    • Prepare for transport.
    • You have moved the child with an adult to your transport vehicle and are preparing to leave for the hospital.
    • What actions should you now take?
    • The initial assessment reveals the following:
    • Airway - The child can speak in short sentences only. He allows you to raise his shirt. You see that he is using his abdominal muscles to move air out of his lungs. You do not hear gurgling or stridor.
    • What do these findings suggest? Treatment? What’s next?
    • Breathing Assessment:
    • Both sides of the chest are rising equally and deeply, with extra effort noted on expiration.
    • With a stethoscope, you hear whistling sounds over the lungs when the patient breathes out. The tracheal sounds are normal.
    • There are 16 breaths in 30 seconds.
    • The skin is pale, but some slight pink tones are now in his face.
    • What do these findings suggest?
    • Treatment?
    • What’s next?
    • Assess circulation:
    • On comparison, central and peripheral pulses are strong, the skin of both the trunk and extremities is warm and pale .
    • Capillary refill is less than 2 seconds.
    • You count 60 beats in 30 seconds when you assess the pulse rate.
    • What do these findings suggest?
    • Treatment?
    • What’s next?
    • Assess AVPU:
    • The child tells you his name, that he was on a class trip to the carnival and the correct day of the week.
    • Using AVPU, what is his level of responsiveness?
    • What does this finding indicate?
    • Treatment? CUPS? What’s next?
    • Using the SAMPLE format, you find the following
    • S Signs and symptoms of respiratory distress
    • A Allergies: Child says only to girls
    • M Medications: Child doesn’t know
    • P Past Medical Problems: Unknown
    • L Last food was a bag lunch from home
    • E Events: He went on a scary spinning ride and rode a pony before he got sick.
  •  
  • Common Respiratory Problems
    • Upper Airway Problems include:
      • Foreign Body Obstruction
      • Croup
      • Epiglottitis
    • Assess and treat the child according to the severity of the child’s condition using the RFI and initial assessment.
  • Foreign Body Obstruction
    • Follow AHA guidelines for complete or partial obstruction.
    • If the obstruction was cleared prior to the arrival of EMTs, child needs transport for evaluation.
    • Irritated tissues may later swell.
    • Piece of FB may still be present.
  • Upper Airway Diseases
    • Share similar signs and symptoms.
    • Assess and treat for the degree of respiratory distress.
    • Exact diagnosis is not needed.
    • Priority is to support breathing effort.
  • Croup
    • Viral cause
    • Fever present but low (up to 102 o )
    • Seal bark cough
    • Stridor
    • Gradual onset of symptoms
    • Symptoms worsen at night
    • Most common in children 2-4 years old
  • Epiglottitis
    • Bacterial cause
    • High fever (102 o to 104 o )
    • Rapid onset of symptoms
    • Drooling
    • Tripod position
    • Most common in children 4-6 years old
  • Treatment for Croup - Epiglottitis
    • Assess and treat according to the severity of the child’s condition.
    • Humidified oxygen by non rebreather face mask or blow by, if mask causes agitation.
    • Keep child with parent, in a comfortable, upright position when possible.
    • Do not place any instrument or oral airway in the mouth.
  • Lower Airway Illnesses
    • Most Common:
    • Asthma
    • Bronchiolitis
    • Pneumonia
    • Assess and treat the child according to the severity of the child’s condition using the RFI and initial assessment.
  • Asthma
    • Causes vary, but often associated with allergy, stress, and strenuous exercise.
    • Lower airways narrow due to spasm.
    • Mucous in airways becomes thickened and causes obstruction of lower airways.
    • When present, wheezes are pronounced with expiration.
    • Wheezes may be absent.
  • Special Concerns-Asthma
    • Children of all ages affected.
    • Humidify oxygen.
    • Prevent agitation.
    • Bring prescribed medications to hospital.
    • Follow regional protocol for albuterol administration.
  • Bronchiolitis
    • Viral cause
    • Wheezes
    • More common in winter months
    • Affects children under 18 months old
  • Apparent Life Threatening Event
    • Usually occurs with infants.
    • Breathing stops for 20 seconds or more.
    • Baby turns blue at the time.
    • On arrival, EMT’s find a normal appearing baby.