3. Overview (2 of 2)
• In the United States, trauma is the most
common cause of death in children
• The elderly are the fastest growing subset
in our population
4. Our Bodies Change Over Time
• There are anatomic
differences between
infants, children, and
adults
• Body systems continue
to develop and mature
in the young
• Aging body systems
show signs of
dysfunction
5. ABCs
• Airway
– Anatomic differences
• Age and size of the patient affects equipment
choice
• Breathing
– Respiratory complications
• Circulation
– Pediatric patients compensate well but
deteriorate quickly
– Geriatric patients compensate poorly and may
be on medications that affect pulse and blood
pressure
6. Anatomy and Physiology:
Pediatric (1 of 5)
• Less body fat, increased elasticity of
connective tissue, and close proximity of
organs to the body surface impair
dissipation of energy applied
• Incomplete calcification of bones and
active growth centers limit absorption of
energy and can increase potential for
injury
7. • Larger head and tongue
– Special attention to positioning
– Potential for airway obstruction
• Conical-shaped trachea
– Uncuffed versus endotracheal tubes
• Shorter trachea
– Danger of main stem intubation
Anatomy and Physiology:
Pediatric (2 of 5)
9. • Respiratory concerns
– Hypoventilation and hypoxia are more likely
than hypovolemia and hypotension
– Injured children can rapidly deteriorate from
labored breathing to tachypnea and progress
to apnea from exhaustion
Anatomy and Physiology:
Pediatric (4 of 5)
10. • Shock
– Most pediatric injuries
do not cause
immediate
exsanguination
– Blood pressure is a
poor indicator of blood
loss and peripheral
perfusion
– Children remain in
compensated shock
longer than adults, but
decline very rapidly
Anatomy and Physiology:
Pediatric (5 of 5)
11. Managing Pediatric Patients
(1 of 5)
• Airway and breathing
– Ensure airway patency
– Provide supplemental oxygen
– Assist ventilations when indicated
• A bag-mask device may be adequate
• Intubate only if bag-mask device is not effective
– Tachypnea and increased effort to breathe
can indicate shock
– Monitor for signs of respiratory fatigue
12. • Circulation
– Evaluate skin color, temperature, and
peripheral perfusion
– Pediatric patients may not show signs of
hypotension until 30% of volume is lost
– Decreasing pulse rate in the face of shock is
an ominous sign
– Fluid replacement
• 20 ml/kg bolus
• May repeat based on clinical response
Managing Pediatric Patients
(2 of 5)
13. • Disability
– Glasgow Coma Scale (GCS)
• Use the pediatric GCS for preverbal children
– Level of consciousness (LOC) is most
important factor
• A child who is lethargic or asleep rather than upset
may indicate hypoperfusion or traumatic brain
injury (TBI)
Managing Pediatric Patients
(3 of 5)
15. • Use appropriately sized equipment
• Preserve body heat
• Frequently reassess patients
• Transport:
– In an age-appropriate device
– To an appropriate facility
Managing Pediatric Patients
(5 of 5)
16. Anatomy and Physiology:
Geriatric (1 of 4)
• Overview
– The body gradually loses its ability to maintain
homeostasis
– Pre-existing conditions can increase mortality
from less severe injuries
– Malnourishment is common
– Geriatric patients may have:
• Slower cognitive responses
• Degenerative diseases
• Decline in sensory acuity
17. • Airway and breathing
– Ventilatory function declines
• Increased stiffness in chest wall
• Alveolar surface decreases
• Decreased ability to saturate hemoglobin with
oxygen
• Circulation
– Pre-existing diseases may compromise
compensatory mechanisms
Anatomy and Physiology:
Geriatric (2 of 4)
18. • Disability
– Slower response to stimuli
– Declining mental and psychomotor activity
– Sensory changes
• Hearing
• Vision
• Pain
• Temperature regulation
Anatomy and Physiology:
Geriatric (3 of 4)
22. Burns: Overview
• All burns are serious, regardless of size
• Burns are not just a skin injury
– Large burns involve multiple organ systems
• Smoke inhalation can be life-threatening
– It is often more dangerous than the burn itself
• Children account for 20% of all burn
victims
– Consider the possibility of intentional injury
(abuse)
23. Burn Assessment
(1 of 4)
• Depth of injury
– Superficial (first-degree)
– Partial-thickness (second-degree)
• Superficial
• Deep
– Full-thickness (third- and fourth-degree)
– Burn depth may evolve over time
26. Burn Assessment
(4 of 4)
• Extent of burn
(burn size
estimation)
– Percent of
body surface
area (BSA)
involved
• Rule of nines
27. Burn Management:
Primary Assessment (1 of 3)
• Conduct the primary assessment
— Airway occlusion may occur as swelling
progresses
• Consider early airway intervention
— Breathing may become compromised from
chest wall eschar or toxic pulmonary injury
• Monitor ventilatory rate, SpO2, and ETCO2
28. Burn Management:
Primary Assessment (2 of 3)
• Circulatory status may be compromised
as fluid leaks into damaged tissue
causing swelling and hypotension
– Ensure IV access and fluid replacement
29. Burn Management:
Primary Assessment (3 of 3)
• Disability
— Altered mentation suggests hypotension or
hypoxia
• Expose
— Allows for complete assessment but may
lead to loss of body temperature
— Cover patient upon completion of
assessment
30. Burn Management
(1 of 3)
• Specific burn therapy
– Stop any ongoing burning
– Cover with dry, sterile nonadherent dressing
(sheet)
• Do not use any ointments or other topical
antibiotic
31. Burn Management
(2 of 3)
• Specific burn therapy:
– Initiate fluid administration
• Parkland formula: total fluid in first 24 hours
(2–4 ml)(body weight in kg)(% BSA burned)
– Half of total fluid should be given in the first 8 hours after
burn
– Second half of total fluid should be given in the next 16
hours after burn
– Adults receive lactated Ringer’s
– Pediatric patients receive 5% dextrose in lactated
Ringer’s
32. Burn Management
(3 of 3)
• Analgesia
–Adequate pain relief is critical
–Narcotic analgesics are indicated for
significant burns
–Ice is not a proper analgesic
• Leads to hypothermia
• May increase the overall size and depth of burn
• Transport to burn center as indicated
33. Extended or Delayed Transport
• Need to provide care for extended time
period
• Continue to provide same type and level of
care
• Be cautious of and monitor for:
– Hyperventilation
– Fluid overload
– Body heat loss
• Continually reassess the patient
35. Multiple Patient Situations
(1 of 2)
• A multiple patient scenario occurs each
time there is more than one patient
• Are there sufficient resources available on
scene to manage all patients?
– Triage is used primarily when the number of
patients exceeds the immediate treatment
and/or transport capacity
36. Multiple Patient Situations
(2 of 2)
• Transport only one critical patient per
ambulance (ideally)
• When possible, distribute patients to all
available hospitals
– Avoid overloading the closest hospital when
possible
38. Trauma Resuscitation Issues
(1 of 3)
• It may be allowable to withhold or
terminate resuscitation efforts in:
– Injuries not compatible
with life
– Pulseless and nonbreathing
blunt trauma victims
– Trauma patients with
witnessed cardiopulmonary
arrest and 15 minutes of
unsuccessful resuscitation and CPR
Courtesy Norman McSwain, MD, FACS, NREMT-P
39. Trauma Resuscitation Issues
(2 of 3)
• Special consideration in trauma
resuscitation must be given to victims who
have greater likelihood of survival,
including:
– Hypothermia
– Immersion incidents
– Lightning strike
– Other situations as defined by local protocol
40. Trauma Resuscitation Issues
(3 of 3)
• In many EMS systems, online medical control
is necessary to confirm the decision to
terminate resuscitation efforts
• Policies and protocols for termination of
resuscitation efforts:
– Should be developed and implemented under the
guidance of the EMS system’s medical director
– Should include notification of the appropriate law
enforcement agencies and medical examiner
• EMS providers should have access to
resources for debriefing and counseling as
needed
Instructor Notes
Lesson 9 will provide participants with an overview of the special considerations to consider when assessing and managing pediatric patients, geriatric patients, patients with burns, multiple patient scenarios, and trauma resuscitation issues.
Instructor Notes
Expand on the following points:
This lesson will focus on special situations that prehospital care providers will encounter regarding pediatric and geriatric patients.
While the priorities of care do not change with age, physiologic differences need to be understood when assessing and treating these patients.
We will also discuss the challenges presented by multiple patient situations and when to withhold or terminate trauma resuscitation.
Instructor Notes
Expand on the following points:
In the United States, trauma is the most common cause of death in children.
The elderly are the fastest growing subset in our population.
Instructor Notes
Expand on the following points:
As infants develop, their vital sign ranges change, their anatomy changes, and their response to injury changes.
Geriatric patients will begin to show signs of changing and failing body systems.
Their musculoskeletal anatomy may change shape and become less flexible.
Medications that geriatric patients may be on can change their response to injury.
Instructor Notes
Expand on the following points:
It is important to understand the differences in physiology, anatomy, and the effect of medications on pediatric and geriatric patients to ensure proper assessment and management.
Airway
There are several anatomic differences that can complicate airway management in a pediatric patient.
Children have a relatively large occiput, tongue, and anterior position of the airway.
The smaller the child, the greater the size discrepancy between the cranium and the midface.
The age and size of the patient affect the equipment choice.
Breathing
When hypoxia occurs in the small child, the body compensates strenuously.
The ventilatory rate (tachypnea) and ventilatory effort increase.
This can produce severe fatigue and result in ventilatory failure, then respiratory arrest, and ultimately a hypoxic cardiac arrest.
Circulation
Pediatric patients compensate well but deteriorate quickly.
Geriatric patients compensate poorly and may be on medications that affect pulse and blood pressure.
Instructor Notes
Expand on the following points:
Pediatric patients may have an increased potential for organ injury because:
They have less fat to provide padding.
They have more elastic connective tissues.
Their organs are closer to the surface of their bodies.
Their bones, which are still developing, bend rather than break.
In some cases, this means that bones absorb less injury, thus transferring that injury to internal organs.
Instructor Notes
Expand on the following points:
Pediatric patients need to have their heads positioned differently than adults to keep the airway from closing.
The relatively large tongue in pediatric patients presents an increased risk of obstruction.
Intubation may need to be performed with an uncuffed endotracheal tube due to the shape of the trachea particularly in infants.
The shortness of the trachea increases the chance of passing the tube into the right lung.
Instructor Notes
Expand on the following points:
This figure illustrates the differences in adult and pediatric airways.
Instructor Notes
Expand on the following points:
Airway and ventilation management is critical to addressing the most frequent needs of these patients.
Failure to appropriately manage airway and ventilation will result in increasing hypoxia and shock that becomes harder to reverse as it progresses.
Hypoventilation and hypoxia are more likely in pediatric patients than hypovolemia and hypotension.
Injured children can rapidly deteriorate from labored breathing to tachypnea and progress to apnea from exhaustion.
Instructor Notes
Expand on the following points:
Pediatric patients compensate very well but can collapse quickly if definitive care does not resolve the bleeding.
Most pediatric injuries do not cause immediate exsanguination.
Blood pressure is a poor indicator of blood loss and peripheral perfusion.
The pulse rate and ventilatory rate have more value in suggesting the severity of the patient’s condition, with bradycardia and tachypnea signaling progression into shock.
Children remain in compensated shock longer than adults, but decline very rapidly.
This figure illustrates that rapid decline in the pediatric patient.
Instructor Notes
Expand on the following points:
Keep the airway open, provide oxygen, and supplement breathing with a bag-mask device if the respirations are inadequate in rate and volume.
Remember, essential airway management can be adequate in ventilating pediatric patients.
The decision to intubate should be weighed against the chance for success and benefit over the success of essential airway management.
Tachypnea and an increased effort to breathe can indicate shock.
In breathing pediatric patients, the longer the patient is in respiratory distress, the more likely respiratory fatigue becomes.
The child may actually stop breathing due to fatigue.
Instructor Notes
Expand on the following points:
Monitoring the pediatric patient’s skin condition along with pulse and breathing is important as the pediatric patient, while compensating well, may crash once the blood loss passes 30% of volume.
Bradycardia signals shock and fluids should be administered.
20 milliliter per kilogram (ml/kg) bolus
For a detailed discussion on fluid replacement, see the section on Hemorrhage in the Pediatric Trauma chapter in PHTLS: Prehospital Trauma Life Support, Eighth Edition.
The formula should be strictly adhered to, as overhydration is a danger.
Instructor Notes
Expand on the following points:
Besides using the pediatric Glasgow Coma Scale (GCS) for preverbal children, it is important to monitor how the child reacts to the environment.
A child should typically be active, upset, or curious in response to injury, illness, and confusing scenes surrounded by noise and strangers.
If the child is lethargic, sleepy, or unresponsive, the illness or injury may be significant.
Level of consciousness (LOC) is the most important factor to evaluate during the disability phase of the primary assessment.
A child who is lethargic or asleep rather than upset may indicate hypoperfusion or traumatic brain injury (TBI).
Instructor Notes
Expand on the following points:
This figure lists the scoring criteria in the pediatric Glasgow Coma Scale.
Instructor Notes
Expand on the following points:
Use appropriately sized equipment.
It is important not to make pediatric patients fit the devices but to size the devices to the pediatric patient.
This ensures adequate spinal immobilization, airway management, and proper patient packaging.
Preserve pediatric patients’ body heat.
Frequently reassess pediatric patients, as their conditions can decline rapidly.
Transport pediatric patients in an age-appropriate device to an appropriate facility.
In some areas, there are specific facilities for pediatric patients, and it is important to know local protocols.
Immobilization of an infant or child in a car seat is no longer recommended because of the concern for axial loading of the spine by the patient’s head when the child remains in an upright position.
Instructor Notes
Expand on the following points:
As we age, our ability to respond to the insult of injury decreases.
The body gradually loses its ability to maintain homeostasis.
Pre-existing chronic illness can complicate the condition of injured geriatric patients.
Pre-existing conditions can increase mortality from less severe injuries.
Unfortunately, malnourishment is common in geriatric patients.
Assessment can become challenging.
Patients may have:
Slower cognitive responses
Degenerative diseases
Decline in sensory acuity
Instructor Notes
Expand on the following points:
Ventilatory function may already be less than optimal due to the aging process and/or pre-existing disease(s), thus making it more difficult for the patient to properly respond to the body’s needs.
There may be:
Increased stiffness in chest wall
Decreased alveolar surface
Decreased ability to saturate hemoglobin with oxygen
Pre-existing diseases may compromise compensatory mechanisms in the circulation system.
Instructor Notes
Expand on the following points:
Prehospital care providers will need to be patient and understanding with geriatric patients who may have:
Slower response to stimuli
Declining mental and psychomotor activity
Sensory changes
Hearing
Vision
Pain
It is also important to protect geriatric patients from temperature extremes, as their capacity to regulate their body temperature is diminished.
Instructor Notes
Expand on the following points:
The aging skeletal system becomes less flexible and can become distorted.
Positioning and padding will be important for comfort and protection of injuries.
Geriatric patients may experience:
Loss of height due to dehydration of vertebral discs
A compressed spinal cord due to the narrowing of the spinal canal
Kyphosis
Porous and brittle bones
Loss of muscle mass
Loss of range of motion
Instructor Notes
Expand on the following points:
Extra care must be taken to fit the bag-mask device properly to ensure adequate seal and ventilations.
Loss of soft tissue and teeth may make obtaining a proper seal between the face and mask difficult.
Fluid resuscitation should be closely monitored to avoid overhydration.
Instructor Notes
Expand on the following points:
This section will discuss the special considerations to take when assessing and managing a patient with burns.
Instructor Notes
Expand on the following points:
Burns, even small ones, can result in permanent disfigurement and disability.
It is important to remember that burns are not just a skin injury but can involve multiple organ systems, including:
Cardiovascular system
Pulmonary system
Renal system
Gastrointestinal system
Immunologic system
Smoke inhalation is often an associated problem and is often more dangerous and more lethal than the burn itself.
Inhalation of carbon monoxide and cyanide can cause hypoxia and must be treated promptly.
Inhalation of other toxic products of combustion produce damage to the lungs that is usually delayed in presentation and may not cause symptoms or signs for several days after exposure.
Children account for 20% of all burn victims.
The reported mechanism of injury (MOI) and pattern of burn injury should be compared for consistency.
Whenever there is inconsistency, consider intentional infliction of burn injury.
Instructor Notes
Expand on the following points:
The assessment of a burn injury generally involves evaluation of the depth and size of the burn.
A burn injury is characterized by the depth to which the skin and underlying tissues have been damaged.
Superficial or first-degree burns involve the outermost layer of the skin, the epidermis, and are characterized by pain and redness of the involved area.
Superficial partial thickness burns will generally heal on their own.
Partial-thickness or second-degree burns involve the epidermis and underlying dermis of the skin.
They are painful and blistered.
Deep partial-thickness burns may require surgical treatment.
Full-thickness burns involve complete damage to the epidermis and dermis and appear charred or leathery.
Full-thickness burns are usually surrounded by areas of superficial or partial-thickness burns.
The areas of superficial or partial-thickness burns are painful while the area of full-thickness involvement will not have sensation.
If tissues or structures such as muscle under the skin are also burned, it is considered a fourth-degree burn.
On initial evaluation, the depth of a burn may be indeterminate.
An underresuscitated, overresuscitated, or inappropriately managed patient with a partial-thickness burn may end up with a full-thickness burn.
Instructor Notes
Expand on the following points:
The first figure illustrates the damage of a fourth-degree burn to the skin, tissues, and muscle.
The second figure is a photo of a fourth-degree burn injury to the arm.
Instructor Notes
Expand on the following points:
This figure demonstrates the multiple levels of burn depths that may exist over the entirety of the burn area.
Instructor Notes
Expand on the following points:
In the field, burn size is generally estimated using the “rule of nines.”
The rule of nines is a topographic breakdown of the body in order to estimate the amount of body surface area (BSA) covered by burns.
It is important to remember that children have different body proportions than adults; therefore, the percentages must be adjusted accordingly.
Instructor Notes
Expand on the following points:
Conduct the primary assessment.
Airway occlusion may occur as swelling progresses.
Consider early airway intervention.
See the Airway section in the Burn Injuries chapter in PHTLS: Prehospital Trauma Life Support, Eighth Edition, for more information about maintaining the airway of a patient with burns.
Breathing may become compromised from chest wall eschar or toxic pulmonary injury.
Monitor the patient’s ventilatory rate, oxygen saturation (SpO2), and end-tidal carbon dioxide (ETCO2).
Instructor Notes
Expand on the following points:
The patient’s circulatory status may be compromised as fluid leaks into damaged tissues, causing swelling and hypotension.
Ensure intravenous (IV) access and fluid replacement.
See the Circulation section in the Burn Injuries chapter in PHTLS: Prehospital Trauma Life Support, Eighth Edition, for more information about fluid replacement in patients with burns.
Instructor Notes
Expand on the following points:
A finding during the disability phase of altered mentation suggests hypotension or hypoxia.
Exposing the patient allows for a complete assessment, but it may lead to loss of body temperature.
Cover the patient immediately upon completion of the assessment.
Instructor Notes
Expand on the following points:
Specific burn therapy includes:
Stop any ongoing burning.
Cover the burn with a dry, sterile nonadherent dressing (sheet).
Do not use any ointments or other topical antibiotic.
Instructor Notes
Expand on the following points:
Initiate fluid administration.
Follow the Parkland formula:
The total fluid in the first 24 hours should equal 2 to 4 ml × the patient’s body weight in kg × percentage of area burned.
Half of this fluid needs to be administered within the first 8 hours of injury, and the remaining half of the volume from hours 8 to 24.
Adults receive lactated Ringer’s.
Pediatric patients receive 5% dextrose in lactated Ringer’s.
Instructor Notes
Expand on the following points:
Burns are extremely painful and require appropriate attention to pain relief beginning in the prehospital setting.
Adequate pain relief is critical.
Narcotic analgesics are indicated for significant burns.
Ice is not a proper analgesic.
It leads to hypothermia.
It may increase the overall size and depth of burn.
Transport the patient to a burn center as indicated.
Instructor Notes
Expand on the following points:
With extended or delayed transport, prehospital care providers need to provide care for an extended time period.
Continue to provide same type and level of care.
Be cautious of and monitor for:
Hyperventilation
Fluid overload
Body heat loss
Continually reassess the patient.
Instructor Notes
Expand on the following points:
This section will discuss the special considerations to take in multiple patient situations.
Instructor Notes
Expand on the following points:
A multiple patient scenario occurs each time there is more than one patient.
Triage is used primarily when the number of patients exceeds the immediate treatment and/or transport capacity.
Identifying the number of patients is a top priority to ensure that the proper resources are made available and that the patients are triaged appropriately.
It is important to recognize the limitations of prehospital care providers and not risk patient safety and proper care by overloading the ambulance beyond the capacity to care for the patients.
Instructor Notes
Expand on the following points:
Transport only one critical patient per ambulance (ideally).
When possible, distribute patients to all available hospitals.
When possible, avoid overloading the closest hospital.
Instructor Notes
Expand on the following points:
This section will discuss the special issues surrounding trauma resuscitation.
Instructor Notes
Expand on the following points:
To ensure the proper resources for a trauma situation, it is important to recognize patients that will not benefit from resuscitation.
This will ensure that resources are used appropriately and that additional resources to care for the dead and their families are made available.
Instead of thrusting them into a hospital environment, which is suited to providing medical care and not psychosocial care
It may be allowable to withhold or terminate resuscitation efforts in:
Injuries that are not compatible with life
Pulseless and nonbreathing blunt trauma victims
Trauma patients with emergency medical services (EMS)-witnessed cardiopulmonary arrest and 15 minutes of unsuccessful resuscitation and cardiopulmonary resuscitation (CPR)
See the National Association of EMS Physicians (NAEMSP), American College of Surgeons Committee on Trauma (ACS COT), and American College of Emergency Physicians (ACEP) Position Paper on withholding or terminating resuscitation efforts for additional information.
Instructor Notes
Expand on the following points:
Special consideration in trauma resuscitation must be given to victims who have greater likelihood of survival, including:
Patients with hypothermia
Immersion incidents
Lightning strike victims
Other situations as defined by local protocol
Instructor Notes
Expand on the following points:
It is important to know what your system’s protocols are in this regard as that is the standard to which you, as a provider in the system, will be held.
The linkage to law enforcement and social services should be well known and protocols for notification followed accordingly.
In many EMS systems, online medical control is necessary to confirm the decision to terminate resuscitation efforts.
The policies and protocols for termination of resuscitation efforts:
Should be developed and implemented under the guidance of the EMS system’s medical director
Should include the notification of the appropriate law enforcement agencies and medical examiner
EMS providers should have access to resources for debriefing and counseling as needed.
Instructor Notes
Expand on the following points:
EMS providers will often encounter special patient populations and situations.
Although special situations do not change the priorities of trauma care, they do affect our assessment and treatment.
The principles of care remain the same as with all trauma patients, but the preferences for management change with special patient populations and environments.
Awareness of the unique aspects of each will optimize patient management and outcome.
Instructor Notes
Allow time for a question and answer session to answer any questions about the topics presented in the lesson.
