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29)Infants And Children
 

29)Infants And Children

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    29)Infants And Children 29)Infants And Children Presentation Transcript

    • Infants and Children
    • Developmental Concerns Infants
      • Newborns and infants – (Birth to 1 yr)
        • Minimal stranger anxiety
        • Do not like to be separated from parents
        • Do not tolerate NRBs
        • Poor thermoregulators = Need to be kept warm
        • Breathing rate best obtained at a distance
          • Note -Chest rise –Color –Level of activity
        • Examine heart and lungs 1 st – Head last
          • Builds confidence
          • Allows optimal assessment before child becomes agitated
    • Developmental Concerns Toddlers
      • Toddlers- (1 yr-3 yrs)
        • Do not like to be touched
        • Do not like being separated from parents
        • Do not like having clothing removed
          • Remove – Examine - Replace
        • Do not tolerate NRB’s
        • Children interpret illness as punishment
          • Assure the pt they have not been “bad”
        • Afraid of needles
        • Fear of pain
        • Trunk to head assessment
          • Builds confidence
          • Done before child becomes agitated
    • Developmental Concerns Preschool
      • Preschool- (3 yrs-6yrs)
        • Do not like to be touched
        • Do not like being separated from parents
        • Do not like to have clothing removed
          • -Remove – Assess - Replace
        • Do not tolerate NRB’s
        • Assure child they were not “bad”
        • Afraid of blood
        • Fear of pain
        • Fear of permanent injury
        • Modest
    • Developmental Concerns Adolescents
      • School age- (6 yrs- 12 yrs)
        • Afraid of blood
        • Fear of pain
        • Fear of permanent injury
        • Modest
        • Fear if disfigurement
      • Adolescent- (12 yrs-18 yrs)
        • Fear of permanent injury
        • Modest
        • Fear of disfigurement
        • Treat as adults
        • May desire to be assessed privately
          • Away from parents/administrators/friends
    • Anatomical/Physiological Concerns: Airway
      • Small airways throughout the resp system
        • Easily blocked by secretions and swelling
      • Tongue is large in relations to small mandible
        • Can be significant airway complication in unresponsive child
      • Positioning airway is different
        • DO NOT hyperextend
      • Infants are obligate nose breathers
        • Suctioning the nasopharynx can improve respirations
      • Children can compensate well for short periods of time
        • Increased breathing rate and effort of breathing
        • Compensation rapidly followed by decompensation
          • Rapid respiratory muscle fatigue
          • General fatigue of the infant
    •  
    • Airway Techniques
      • Airway opening
        • Head tilt chin lift = no trauma
        • Modified jaw thrust = trauma
        • Do not hyperextend
        • Infants below 1 y/o
          • “ sniffing position”
        • Small children 1-8 yrs
          • Extend but do not hyperextend
    • Another type of sniffing position…
    • Suctioning
      • Suctioning
        • Blood, vomit, small particulate matter from airway
          • Rigid suction catheter
          • Insert only as far back as you can see
          • Pressure less than 300 mmHg
          • Should not exceed 100 mmHg in newborns
          • Suction for 15 seconds or less
        • Nasopharynx
          • Soft suction catheter
          • Suction for 15 seconds or less
        • If appropriate, hyperventilate the pt before and after suctioning
        • If airway is full of secretions that cannot be easily cleared
          • Log roll pt onto side
    • Airway Adjuncts
      • Adjuncts
        • Oral airways
          • Not for initial artificial ventilation
          • Should not have a gag reflex
          • Size as normal
          • Use tongue depressor
            • Insert tongue blade to base of tongue
            • Push down against tongue while lifting upwards
            • Insert OPA directly in without rotation
        • Nasal airways
          • Not for initial artificial ventilation
          • Size as normal
          • Insert as normal
          • Contraindicated in trauma
    • Oxygen Deliver
      • Oxygen Delivery
        • Nonrebreathers
        • Blow By
          • Hold O2 tubing 2” from face
          • Insert tubing into a paper cup or stuffed animal
      • Artificial Ventilation
        • Mask/bag size determined by age/size of pt
          • -Neonatal – Pediatric - Child
        • Consider trauma
          • Modified jaw thrust
          • Manual in line stabilization
        • Mouth to mask ventilation
        • Use of BVM
          • Squeeze bag slowly and evenly allowing chest rise
          • Rate at 20 breaths per minute
          • Provide O2 at 100% using an O2 reservoir
    • Infants and Children Assessment
      • Pediatric Assessment Triangle
      • General impression can be obtained from overall appearance (Well v. sick)
        • Mental Status
        • Effort of breathing
        • Color
        • Quality of cry/speech
        • Interaction to parents/environment
          • Normal behavior based on age
          • Playing
          • Moving around
          • Attentive v non attentive
          • Eye contact
          • Recognized parents
          • Responds to parents calling
        • Emotional state
        • Response to the EMT
        • Tone/body position
    • Approach to Evaluation
      • Begin from across the room
        • MOI
        • Scene size up
        • General impression
        • Respiratory assessment
          • Note chest expansion/symmetry
          • Effort of breathing
          • Nasal flaring
          • Stridor, crowing, noisy
          • Retractions
          • Grunting
          • Respiratory rate
        • Perfusion assessment
          • Skin color
    • Approach to Evaluation “Hands on”
      • “ Hands on” Approach
        • Assess breath sounds
          • Present
          • Absent
          • Stridor or wheezing
        • Assess circulation
          • Assess brachial or femoral pulse
          • Assess peripheral pulse
          • Assess capillary refill
          • Assess BP in children 3 y/o and older
          • Assess skin color, temperature, moisture
        • Detailed physical exam
          • Trunk to head approach
          • Situation and age dependant
          • Should help reduce infant/child anxiety
    • Common Problems Partial Airway Obstruction
      • Partial Airway Obstruction
        • Infants who are alert and sitting
      • S/S
        • Stridor, crowing, noisy
        • Retractions on inspiration
        • Pink
        • Good peripheral perfusion
        • Still alert, not unconscious
      • Emergency care
        • Allow position of comfort
          • Assist younger child to sit up
          • Do not lay down
          • May sit on parents lap
        • Offer O2
        • Transport
        • Do not agitate child
        • Limited exam
    • Common Problems Complete Airway Obstruction
      • Complete Airway Obstruction
        • -Total blockage of airway -OR-
        • Partial obstruction with -AMS – Cyanosis
      • S/S
        • No crying/speaking and cyanosis
        • Childs cough becomes ineffective
        • Increased resp difficulty with stridor
        • Loss of consciousness
        • AMS
      • Emergent clearing of airway
        • Infant procedures
        • Child procedures
      • Attempt artificial ventilation with BVM and good seal
    • Airway Obstructions
      • Complete obstructions
        • Infants less than 1 y/o
          • Back blows/chest thrusts
          • Visual foreign body removal
        • Children 1 y/o+
          • Abdominal thrusts
          • Visual foreign body removal
    • Upper v Lower Respiratory Presentations
        • Upper Airway Obstruction
          • Stridor on inspiration
        • Lower Airway Disease
          • Wheezing and breathing effort on exhalation
          • Rapid breathing without stridor
        • Complete Airway Obstruction
          • No crying
          • No speaking
          • Cyanosis
          • No coughing
    • S/S of Resp Compromise
      • S/S of Early Respiratory Distress
        • Nasal flaring
        • Retractions
          • Intercostal, Supraclavicular, Subcostal
          • Adnominal, Neck
        • Stridor
        • Audible wheezing
        • Grunting
      • S/S of Progressive Respiratory Distress
        • Rate above 60 breaths per minute
        • Cyanosis
        • Decreased muscle tone
        • Severe use of accessory muscles
        • Poor peripheral perfusion
        • AMS
        • Grunting
      • S/S of Respiratory Arrest
        • Rate less than 10 breaths per minute
        • Limp/flaccid muscle tone
        • Unconscious
        • Slow, absent heart rate
        • Weak, absent distal pulses
    • Treatment of Resp Compromise
      • Emergency Care of Respiratory Compromise
        • O2
        • O2 and Assist ventilation is severe distress
          • Resp distress and AMS
          • Cyanosis with O2
          • Resp distress with poor muscle tone
          • Resp failure
        • Provide O2 and ventilate with Resp arrest
    • Common Problems Seizures
        • General comments:
          • Rarely life threatening in children with a Hx
          • However, consider any seizure to be life threatening
          • May be brief or prolonged
          • Although they can be brief there could be a more serious underlying problem
        • Assessment
          • Assess for injuries incurred by seizure activity
        • Caused by
          • Fevers – Infections – Trauma – Hypoglycemia –Poisoning – Hypoxia – Idiopathic
        • Hx of seizures
          • Has the child has prior seizures?
          • If yes, is this the normal seizure pattern?
          • Has the child taken any anti seizure medications?
    • Treatment of Seizures
      • Assure airway position and patency
      • If no C-spine trauma place pt on side
      • Have suction ready
      • Provide O2
      • Treat S/S of respiratory compromise if found
        • Inadequate breathing and AMS may follow a seizure
      • Transport
    • Common Problems Altered Mental Status
        • Caused by
          • Hypoglycemia
          • Poisoning
          • Seizure
          • Infection
          • Head trauma
          • Hypoxia
          • Hypoperfusion
        • Emergency Care
          • Assure patency of airways
          • Be prepared to artificially ventilate/suction
          • Transport
    • Common Problems Poisoning
      • Poisoning
        • Common reason for EMS activation
        • Identify suspected container through Hx
        • Bring container to hospital if possible
      • Emergency Care
        • Responsive Pt
          • Contact med control
          • Consider activated charcoal
          • O2
          • Transport
          • Monitor pt for AMS/unresponsiveness
        • Unresponsive Pt
          • Assure patency of airway
          • Be prepared to artificially ventilate
          • O2
          • Call med control
          • Transport
          • Rule out trauma as cause of AMS
    • Common Problems Fever
      • Fever
        • General comments:
          • Many causes, rarely life threatening
          • Severe case is meningitis
          • Fever with a rash is a significant finding
          • May precipitate a febrile seizure
        • Emergency Care
          • Transport
          • Be prepared for a seizure
    • Common Problems Shock
      • Shock
        • General comments:
          • Rarely a primary cardiac event
        • Common Causes:
          • Diarrhea and dehydration
          • Trauma
          • Vomiting
          • Blood loss
          • Infection
          • Abd injuries
        • Less common causes:
          • Allergic reactions
          • Poisoning
          • Cardiac
        • S/S
          • Rapid resp rate
          • Pale, cool, clammy skin
          • Weak/absent peripheral pulses
          • Delayed capillary refill
          • Decreased urine output
          • ALOC/AMS
          • Absence of tears even when crying
    • Treatment of Shock
      • Assure airway/O2
      • Be prepared to artificially ventilate
      • Manage bleeding if present
      • Place pt in shock position
      • Keep warm
      • IMMEDIATE transport
      • Detailed exam en route if time permits
    • Common Problems Water Related Accidents
      • Near Drowning
        • Ventilation is TOP priority
        • Consider
          • possible trauma
          • hypothermia
          • possible ingestion (alcohol, etc)
        • Protect airway
        • Suction if necessary
      • Secondary Drowning Syndrome
        • Minutes to hours after the event
        • Deteriorate after breathing normally
        • Therefore, transport ALL near drowning pts
    • Common Problems SIDS
      • Sudden Infant Death Syndrome (SIDS)
        • S/S
          • Sudden death of infant within 1 st year
          • Causes are many and not well understood
          • Most commonly found during early morning
        • Emergency Care
          • Try to resuscitate unless rigor mortis
          • Parents will be in distress
          • Avoid comments that may place blame
    • Infants and Children Trauma
      • Injuries are the #1 COD in infants/children
      • Blunt injury is mot common
      • Pattern of injury if different from adults
        • Motor Vehicle Passengers
          • Unrestrained = Head/Neck injuries
          • Restrained= Abdomen and spinal injuries
        • Struck with riding bicycle
          • Head, Spine, Abd injury
        • Falls from heights
          • Injuries to head/neck
        • Burns
        • Sport injuries
          • Head/neck
        • Child abuse
    • Infants and Children Trauma: Specific Body Regions
      • Head
        • Maintain airway via modified jaw thrust
        • More likely to sustain head injuries
        • S/S of shock with head injury suggest other injuries
        • Respiratory arrest is common secondary to head injury
        • Common S/S = Nausea/Vomiting
        • Major airway complication = Tongue
      • Chest
        • Soft very pliable ribs
        • May have injuries without external signs
      • Abdomen
        • More common in children than adults
        • Often a source of hidden injuries
        • ALWAYS consider this in multi-system trauma pt who is deteriorating without external S/S
        • Be aware of complications of gastric distention
      • Extremities
        • Manage in the same manner as adults
    • Other Considerations PASG, Burns
      • Pneumatic Anti Shock Garments
        • Use ONLY if child fits
        • Do not inflate abd compartment
        • Indication
          • S/S hypoperfusion
          • S/S of pelvic instability
      • Criticality of burns
        • Cover with sterile dressing
        • Possible transport to a burn center per protocol
    • Care of the traumatically injured pediatric
      • Assure airway position and patency
      • Use modified jaw thrust
      • O2
      • Assist ventilation in resp distress
      • Ventilate with BVM in resp arrest
      • Immobilization
      • IMMEDIATE transport
    • Abuse and Neglect
      • Abuse
        • Improper or excessive action so as to injure or cause harm
      • Neglect
        • Giving insufficient attention/respect to an individual who has a right to that attention
      • S/S of Abuse
        • Multiple bruises in different stages of healing
        • Injury inconsistent with MOI
        • Repeated calls to the same location
        • Fresh burns
        • Parents seem inappropriately unconcerned
        • Conflicting stories
        • Fear on the part of the child to discus how they were hurt
      • S/S of Neglect
        • Lack of adult supervision
        • Malnourished appearing child
        • Unsafe living environment
        • Untreated chronic illness
      • CNS injuries are the most lethal in the field (Shaken Baby Syndrome)
      • Do NOT accuse in the field
      • Required reporting by state law
        • What you SEE and what you HEAR
        • NOT what you THINK
    • Virginia Child Abuse Hotline
      • In State
        • (800) 552-7096
      • Out of State
        • (804) 786-8536
    • Special Needs Children
      • Examples:
        • Premature babies with lung disease
        • Babies and children with heart disease
        • Infants/children with neurological disease
        • Children with chronic diseases
      • Often these pt are at home technologically dependant
    • Infants and Children Special Needs Children
      • Tracheostomy Tube
        • Complications:
          • Obstruction, Bleeding, Air leak, Dislodged, Infection
        • Care:
          • Maintain open airway
          • Suction
          • Maintain position of comfort
          • Transport
      • Home Ventilators
        • Care:
          • Assure patency of airway
          • Artificially ventilate with O2
          • Transport
          • The parents will be familiar with the equipment
      • Shunts
        • Device running from brain to abd to drain excess CSF
        • Will find reservoir on side of skull
        • Be prepared for AMS
        • Prone to resp arrest
          • Manage airway
          • Assure adequate ventilation
          • Transport
    •  
    •  
    • Infants and Children Special Needs Children
      • Central Lines
        • Complications
          • Cracked line
          • Infection
          • Clotting off
          • Bleeding
        • Care
          • If bleeding, apply pressure
          • Transport
      • Gastronomy Tube and Gastric Feeding
        • Tube inserted directly into stomach for feeding
        • Be alert for breathing problems:
          • Assure adequate airway
          • Have suction ready
          • If diabetic Hx, anticipate AMS
          • O2
          • Transport
            • Sitting
            • Lying on Right side, head elevated
    • Family Response
      • Multiple patients
        • Child cannot be cared for in isolation from family
      • Calm, supportive interaction with family
        • Improves ability to deal with child
        • Calm parents = Calm child
        • Agitate parents = Agitate child
      • Parents may respond with anger/hysteria
      • Allow parents to remain part of the care unless condition does not allow
      • Parents should instructed to calm child
        • Transport in position of comfort
        • Hold O2, etc
      • Parents are EXPERTS on what is normal and abnormal for their child
    • Provider Response
      • Anxiety from lack of experience
      • Fear of failure
      • Stress of identifying pt with own child
      • Much of adult learning applies to children
      • REMEMBER the differences
      • PRACTICE
    • That does it…