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Alexander ch44 lecture
1.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Advanced EMT A Clinical-Reasoning Approach, 2nd Edition Chapter 44 Pediatric Emergencies
2.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. • Applies a fundamental knowledge of growth, development, aging, and assessment findings to provide basic emergency care and transportation for a patient with special needs. Advanced EMT Education Standard
3.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. 1. Define key terms introduced in this chapter. 2. Discuss the leading reasons that pediatric patients require medical attention. 3. Explain the special considerations in dealing with the caregiver of a sick or injured child. 4. Describe the major anatomic, physiological, and developmental characteristics of pediatric patients in each of the following age groups: infant, toddler, preschooler, school-age child, and adolescent. Objectives (1 of 5)
4.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. 5. Give examples of modifications of patient assessment and management techniques that increase the likelihood of cooperation by patients in each of the following age groups: infant, toddler, preschooler, school-age child, and adolescent. 6. Given a description of vital signs for pediatric patients of various ages, classify the values as normal or abnormal. 7. Use the pediatric assessment triangle to determine a pediatric patient’s status. 8. Recognize signs of respiratory distress, respiratory failure, and respiratory arrest in pediatric patients. Objectives (2 of 5)
5.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. 9. Describe the presentation and assessment-based prehospital management of conditions common to pediatric patients. 10.Demonstrate emergency medical care techniques for pediatric patients, including airway management, CPR, fluid resuscitation, management of partial and complete foreign body airway obstruction, medication administration, oxygen administration, and ventilation. 11.Describe special considerations for scene size-up in suspected SIDS. Objectives (3 of 5)
6.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. 12.Describe special considerations for assisting family members in suspected SIDS. 13.Describe the importance of the presence of parents during pediatric resuscitation. 14.Integrate consideration of a pediatric patient’s size and anatomy into the assessment of mechanism of injury. 15.Demonstrate removal of a pediatric patient from a child car seat. 16.Demonstrate proper spinal motion restriction of a pediatric patient. Objectives (4 of 5)
7.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. 17.Recognize indications of child abuse and neglect. 18.Explain special considerations in managing situations in which you suspect child abuse or neglect. 19.Discuss ways in which you can manage the stress that can be associated with pediatric calls, both during and after the calls. Objectives (5 of 5)
8.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Introduction • Caring for critically ill or injured child can be stressful experience for EMS providers. • Take into account differing epidemiology of illness and injury in children, and anatomic, physiological, and psychosocial differences as you evaluate presenting problem.
9.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Think About It • What criteria should Vic and Marcel use to develop a general impression of the patient’s condition? • What questions should they ask of the parents? • How should they proceed with the assessment of an infant?
10.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Figure 44-1 Anatomic and physiologic considerations in infants and children.
11.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Development Review (1 of 8) • Infants – 1 month of age to 1 year of age – Body systems immature – Liver large for size of abdomen; not well protected – Abdominal wall thin – Ribs pliable; transmits energy forces to organs – Kidneys do not efficiently concentrate urine; increased risk of dehydration – Bones softer and less well formed
12.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Development Review (2 of 8) • Infants (continued) – Skeletal muscle mass small; less strength, protection, and heat production – Head disproportionately large; neck weak – Greater surface-area-to-volume ratio; increased heat loss from body – Prone to hypothermia; must be kept warm – Airway obstruction can occur very easily; tongue takes up larger portion of oral cavity – Nose small and soft – Lungs fragile and easily damaged
13.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Development Review (3 of 8) • Infants (continued) – Respiratory failure/arrest occurs quickly – Water vapor lost with every breath; leads to dehydration – Poor feeding, vomiting, diarrhea, fever can result in significant dehydration – Immune system immature; less able to fight infection – Fever in infants always a concer – Crying only way of communicating
14.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Development Review (4 of 8) • Toddlers and preschool children – Toddler: child 1 to 3 years of age – Preschoolers: child 3 to 6 years of age – Head still proportionally large – Airway small; can be obstructed easily – Vulnerable to communicable diseases. – Ear infections and upper and lower respiratory tract infections common
15.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Development Review (5 of 8) • Toddlers and preschool children (continued) – Croup, bronchiolitis, pneumonia, and epiglottitis can lead to respiratory distress. – Strangers can provoke anxiety at this age. – Establish rapport, gain child’s trust, and communicate in a way the child can understand.
16.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Development Review (6 of 8) • School-age children – 6 through 12 years of age – Physical proportions more adult-like – Approval and acceptance important – Beginning to develop understanding of illness, loss, death, dying; need adults’ assistance in coping with fears – Modesty and need for privacy
17.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Development Review (7 of 8) • Adolescents – 12 through 18 years of age – Vital signs approach adult values – Physical growth nearly complete in later years – Brain has not yet developed adult judgment; handles emotions differently
18.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Development Review (8 of 8) • Adolescents (continued) – Sense of invulnerability – Risky behaviors – Rates of depression and suicide increase – Assessment and management of anatomic and physiological aspects similar to adults – Keep in mind psychosocial differences.
19.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Appropriate equipment; differences between adults and pediatric patients • Principles of scene size-up remain the same. – Stay focused in order to be thorough. • Take into account reactions and needs of parents or caregivers. – Unless parent(s) unable to cooperate, no reason to separate child from parent(s).
20.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Table 44-1 Equipment for Pediatric Prehospital Care • Length-based resuscitation tape, such as a Broselow tape • Pediatric stethoscope • Pediatric blood pressure cuffs • Pediatric pulse oximeter sensor • Pediatric oropharyngeal and nasopharyngeal airways • Pediatric advanced (supraglottic) airways • Pediatric oxygen masks • Pediatric bag-valve-mask device • Pediatric cervical collars in a variety of sizes • Bulb syringe • Blankets for warmth and padding • 60 gtts/mL IV tubing • Volumetric IV device, such as a Buretrol • 24-, 22-, and 20-gauge IV catheters • 25 percent dextrose • 10 percent dextrose • Pediatric long-bone splints • Pediatric car seat and restraint devices for transport
21.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Scene size-up – Potential abuse or neglect requires law enforcement presence. – When child abuse or neglect or sudden infant death syndrome (SIDS) is suspected, there are observations you must make and document. – General impression facilitated by use of pediatric assessment triangle (PAT)
22.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Table 44-2 Indications of Child Abuse and Child Neglect • Injuries inconsistent with history provided • Bruises over soft areas (buttocks, abdomen, cheeks, thighs, upper arms), as opposed to bony areas such as the forehead or shins • Multiple injuries in various stages of healing • Unusually fearful child • Specific wound patterns such as cigarette burns, hand marks, belt buckle impression, human bite marks • Clearly delineated burn marks, burn marks in the shape of a specific object • Lack of adequate supervision • Injuries to the genitals • Untreated illness • Delay in reporting illness or injury • Malnourishment, lack of food • Sexual behavior or unusual knowledge of sexual activity • Unsafe living environment
23.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Figure 44-2 Elements of the pediatric assessment triangle.
24.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Appearance – Muscle tone – Interactiveness – Consolabilty – Eye contact – Speech or crying
25.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Work of breathing – Abnormal airway noise – Abnormal positioning – Retractions – Nasal flaring • Circulation to the skin – Skin color
26.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Primary assessment – If unresponsive and not breathing normally, confirm unresponsiveness; check for pulse. – Check infant’s pulse at brachial artery. – Check carotid pulse of older child. – If pulse is not detected within 10 seconds, begin chest compressions according to American Heart Association (AHA) guidelines.
27.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Table 44-3 (1 of 2) Pediatric CPR Patient Age Indication and Initiation Hand Position Compression Depth Compression Rate per Minute Ratio of Compressions to Ventilations Child (one to eight years) Unresponsive, not breathing or agonal breathing, no pulse, or heart rate < 60 with poor perfusion. A lone rescuer performs two minutes of CPR and then activates EMS. An EMS team can perform interventions simultaneously. One or two hands, depending on size of child, over the lower half of the sternum Two inches or at least one-third of the anterior– posterior dimension of the chest 100–120/min 30:2 with one rescuer; 15:2 with two Rescuers
28.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Table 44-3 (2 of 2) Pediatric CPR Patient Age Indication and Initiation Hand Position Compression Depth Compression Rate per Minute Ratio of Compressions to Ventilations Infant (less than one year) Unresponsive, not breathing or agonal breathing, no pulse, or heart rate, 60 with poor perfusion. A lone rescuer performs two minutes of CPR and then activates EMS. An EMS team can perform interventions simultaneously. Two fingers over the sternum just below the intermamma ry line or two thumbs encircling if two rescuers are present One and one-half inches or at least one third of the anterior–posterior dimension of the chest 100–120/min 30:2 with one rescuer; 15:2 with two Rescuers Source: American Heart Association. 2015. “Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC.” Dallas, TX: American Heart Association. https://eccguidelines.heart.org/wp- content/uploads/2015/10/2015-AHA-Guidelines-Highlights-English.pdf
29.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Primary assessment (continued) – Common cause of cardiac arrest in pediatric patients is hypoxia due to respiratory failure and respiratory arrest. – AHA allows for EMS provider judgment in making ventilation higher priority during cardiopulmonary resuscitation (CPR). – If patient is responsive, or unresponsive but breathing, assess airway, breathing, and circulation.
30.
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2012 Pearson Education, Inc. All Rights Reserved. Figure 44-3 (A) When a child is supine without padding beneath the shoulders, the neck can flex, resulting in airway obstruction. (B) Pad beneath the shoulders to maintain proper alignment of airway structures, with the neck in a neutral position.
31.
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2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Primary assessment (continued) – Assess for partial or complete airway obstruction. – Use padding under shoulders of smaller patients. – Assess need for assisted ventilations. Be prepared to intervene quickly with any child who has signs of respiratory distress. – If hypoxia is evident or likely, provide supplemental oxygen. – Use blow-by oxygen.
32.
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2012 Pearson Education, Inc. All Rights Reserved. Figure 44-5 Administering oxygen to an infant using the blow-by method.
33.
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2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Primary assessment (continued) – Children’s blood volume small; shock can occur with little volume loss – Control hemorrhage; high index of suspicion for internal bleeding based on MOI – Keep patient with blood loss warm.
34.
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2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • What are the signs of shock (hypoperfusion) in an infant or child?
35.
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2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Secondary assessment – Younger pediatric patient’s inability to give chief complaint; limited language skills to elaborate on chief complaint – Obtaining medical history may be difficult if parent is not available on scene. – Obtain SAMPLE history and chief complaint using OPQRST to best of your ability.
36.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Secondary assessment (continued) – Specific history questions to ask: Displaying normal activity level? Recent fever or illness? Is there a rash? Volume of oral intake? Urinary output? Diarrhea or vomiting? Current or past medical problems? Birth complications? Premature? Up to date on vaccinations?
37.
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2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Secondary assessment (continued) – Level of responsiveness determined using AVPU method; Pediatric Glasgow Coma Scale more precise assessment – Know normal values of pediatric vital signs.
38.
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2012 Pearson Education, Inc. All Rights Reserved. Table 44-4 Pediatric Glasgow Coma Scale Eye opening > One Year 4 Spontaneous 3 To verbal command 2 To pain 1 No response < One Year Spontaneous To shout To pain No response Best motor response > One Year 6 Obeys 5 Localizes pain 4 Flexion withdrawal 3 Flexion abnormal (decorticate rigidity) 2 Extension (decerebrate rigidity) 1 No response < One Year Localizes pain Flexion withdrawal Flexion abnormal (decorticate rigidity) Extension (decerebrate rigidity) No response Best verbal response Five Years 5 Oriented and converses 4 Disoriented and converses 3 Inappropriate words 2 Incomprehensible sounds 1 No response Two to Five Years Appropriate words and phrases Inappropriate words Cries and/or screams Grunts No response 0–23 months Smiles, coos, cries appropriately Cries Inappropriate crying and/or screaming Grunts No response
39.
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2012 Pearson Education, Inc. All Rights Reserved. Table 44-5 Normal Pediatric Vital Signs Age Group Respiratory Rate (per minute) Heart Rate (per minute) Systolic Blood Pressure in mHg Temperature in °F Newborn 30 to 60 100 to 180 70 to 90 98 to 100 Infant 25 to 40 100 to 160 70 to 90 98 to 100 Toddler 24 to 30 80 to 130 72 to 100 98.6 to 99.6 Preschool child 22 to 34 80 to 120 78 to 104 98.6 to 99.6 School-age child 18 to 30 70 to 110 80 to 115 98.6 Adolescent 12 to 20 60 to 105 88 to 120 98.6
40.
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2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Secondary assessment (continued) – Blood pressures are difficult to obtain (< 3 years old) and interpret. – Capillary refill time is an indication of perfusion status in young children. – Base physical exam on chief complaint, overall presentation, and history.
41.
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2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Secondary assessment (continued) – Unusual lethargy, flat affect, lack of interest in surroundings – Unusual patterns of bruising; injuries unusual in child; unusual pattern or location – Rashes and petechiae; possible infection or allergic reaction – Absence of tears can be sign of dehydration – Drainage or bleeding from ear – Signs of possible toxic ingestion; discoloration or burns around the mouth; unusual odor
42.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Secondary assessment (continued) – In infant, fontanelles bulging or depressed – Distended abdomen – Child favors, protects, refuses to use an extremity
43.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Clinical-reasoning process – Be prepared to change general impression and patient’s priority for transport. – Epidemiology of illnesses and injuries are different in children than in adults. – Pediatric population: compensates well for illnesses and injuries short term
44.
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2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Clinical-reasoning process (continued) – Energy stores limited; can deteriorate with little warning – High index of suspicion for shock and impending respiratory failure based on MOI and nature of illness (NOI) – Whenever possible, transport pediatric patients to facility with pediatric emergency department.
45.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Treatment – Always use equipment and supplies appropriate for pediatric patients. – Use basic life-support measures for managing airway, breathing, circulation. – Lower volume and higher rate of ventilations
46.
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2012 Pearson Education, Inc. All Rights Reserved. Table 44-6 Pediatric Bag-Valve-Mask Ventilation Age Ventilations per Minute Approximate Volume per Breath Neonate 30 6 to 8 mL/kg (approximately 20 to 30 mL), use bag-valve-mask with no greater than 250 mL volume Infant 20 to 25 6 to 8 mL/kg (approximately 20 to 80 mL), use a bag-valve-mask device with 250 to 500 mL volume Child, one to eight years 12 to 20 7 mL/kg (approximately 70 to 200 mL)
47.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Treatment (continued) – If spinal motion restriction is required, place padding under body to avoid hyperflexion of cervical spine. – Use cervical collars and splinting devices appropriate to child’s size. – If dehydrated, has lost blood volume, or requires intravenous medications, start IV; follow your protocols. – Particularly prone to hypothermia
48.
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2012 Pearson Education, Inc. All Rights Reserved. General Assessment and Management of Pediatric Patients • Reassessment – Pediatric patients can deteriorate quickly; reassess frequently. – Compare subsequent findings to baseline findings to identify trends. – Monitor effects of any treatments initiated.
49.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies – Asthma, infectious respiratory illnesses, cystic fibrosis, anaphylaxis. – Pediatric patients can deteriorate rapidly from respiratory distress to respiratory failure to respiratory arrest. – Quickly identify problem; take measures to restore ventilation and oxygenation.
50.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies (continued) – May display grunting with expiration – Nasal flaring; retraction above clavicles and between ribs may be prominent; may also demonstrate belly breathing – As hypoxia develops, pediatric patients exhibit bradycardia.
51.
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2012 Pearson Education, Inc. All Rights Reserved. Table 44-7 Indications of Pediatric Respiratory Distress • Abnormal sounds, such as stridor, crowing, wheezing, grunting, hoarseness, snoring, coughing, gagging, gasping • Tachypnea • Bradypnea • Tachycardia • Bradycardia • Diminished air movement • SpO2 < 95% • Tripod position • Suprasternal or intercostal retractions • Use of neck muscles • Nasal flaring • Head bobbing • Cyanosis or pallor • Fatigue/lethargy • Seesaw breathing • Unresponsiveness or limp muscle tone
52.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies (continued) – Immediate intervention in pediatric patient who appears lethargic, limp, or cyanotic – Pediatric asthma patients may exhibit dry cough; indicates inflammation of lower airways. – Begin oxygen administration; use humidified oxygen, if available.
53.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies (continued) – For patients in respiratory failure, immediately establish airway, assist with ventilations, and provide supplemental oxygen. – Intravenous fluids are beneficial with asthma to reverse or prevent dehydration; follow protocols. – Be prepared to provide airway and start ventilations by bag-valve-mask device.
54.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies (continued) – Haemophilis influenza B (Hib) vaccination all but eradicated epiglottitis in this age group. – If epiglottitis suspected, do not place anything in mouth; do not agitate patient. – Transport without delay. – Laryngotracheobronchitis (croup): viral infection of lower airway, worsens at night, “seal bark” cough – Humidified oxygen preferred to prevent drying, irritation, and further swelling of airway.
55.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies (continued) – Pertussis: serious, sometimes fatal disease that causes coughing fits; may last 10 or more weeks – Patients gasp for air following coughing fits; “whooping” cough. – DTaP vaccine not recommended until 2 months of age; series of five vaccinations to confer immunity.
56.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies (continued) – Bronchiolitis: acute viral lower airway disease; children 2 months to 2 years of age – Airway constriction; expiratory wheezing, tachypnea, signs of respiratory distress – Respiratory syncytial virus (RSV) common cause – Assess significant dehydration; consider fluid replacement if dehydration severe.
57.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies (continued) – Except in newborns, cough and fever common early signs of pediatric pneumonia – Tachypnea, respiratory distress, lethargy, irritability, vomiting – Assist ventilations if respiratory failure or arrest. – Continuous positive airway pressure (CPAP), if permitted by protocol, may be beneficial for patients in severe respiratory distress.
58.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies (continued) – Upper respiratory infections with rhinorrhea and cough common – Often accompanied by low-grade fever and can result in otitis media. – In infant’s, nasal secretions can significantly obstruct breathing.
59.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies (continued) – Anaphylaxis: respiratory emergency with signs of upper or lower airway obstruction (dyspnea, stridor, wheezing) – Include questions about allergies and exposure to allergens. – Determine if child has epinephrine autoinjector and whether it has been used.
60.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Respiratory emergencies (continued) – Cystic fibrosis (CF): two defective genes, one inherited from each parent, results in production of extremely viscous mucus – In respiratory tract, thick secretions obstruct airways and lead to life-threatening infection. – Do not withhold oxygen; humidified preferred; IV fluids may assist in hydrating mucus. – CPAP useful for impending respiratory failure.
61.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Pediatric cardiovascular disorders – Cardiac arrest is usually due to hypoxia. – Adolescents known to suffer cardiac arrest during strenuous activity. – Cardiac arrest occurs from commotio cordis, which is a direct blow to chest at vulnerable point in cardiac cycle. – For adolescents, early chest compressions with minimal interruption, rapid defibrillation
62.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Pediatric cardiovascular disorders (continued) – Most pediatric cardiac problems are due to congenital abnormalities. – Uncorrected congenital heart defects can lead to poor perfusion and hypoxia. – Treat patient for shock; pay particular attention to correcting hypoxia and improving circulation.
63.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Sudden Infant Death Syndrome (SIDS) – SIDS: sudden death of infant under 1 year of age that cannot be explained despite case investigation and autopsy; diagnosis of exclusion – Apparent life-threatening event (ALTE): combination of apnea, color change, limpness, choking, or gagging – MUST transport all infants with ALTE to emergency department for evaluation
64.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Sudden Infant Death Syndrome (SIDS) (continued) – In the absence of signs of presumptive death, begin CPR in suspected SIDS patient; transport with continuing resuscitative efforts. – All cases of sudden, unexpected death fall under the jurisdiction of medical examiner. – If child is not a candidate for resuscitation, treat scene as potential crime scene.
65.
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2012 Pearson Education, Inc. All Rights Reserved. Table 44-8 Documenting the Scene in Suspected Sudden Infant Death Syndrome • How was the child found on your arrival? • Where was the child when the parents found him? What kind of surface was the child on when found? • Were there any pillows, loose bedding, stuffed animals, or other objects where the child was found that could have posed an asphyxiation hazard? • What clothing was the child wearing? Could it have posed an asphyxiation hazard? • If the child was in a crib, were there any signs of defect, such as an opening in which the child could have become wedged? • What was the general condition of the residence? • Who was present at the scene, and what was the demeanor of each? • Was rigor mortis or livor mortis present? • What was the skin temperature of the patient? • Were there any apparent injuries or marks?
66.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Sudden Infant Death Syndrome (SIDS) (continued) – Do not misinterpret normal signs of death as signs of abuse. – In cases of pediatric resuscitation, allow parents to be in attendance if possible. – In all cases, parents require emotional support. – Recognize signs of acute stress reaction in yourself and others who responded; be prepared to seek assistance.
67.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Infectious diseases – Meningitis: viral or bacterial; inflammation and swelling of meninges that surround central nervous system. – Viral meningitis is less severe; bacterial meningitis can be fatal. – Viral meningitis: fever, headache, photophobia, stiff neck – Bacterial meningitis: seizures and altered mental status
68.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Infectious diseases (continued) – Meningococcal bacteria can enter blood, causing damage to blood vessels, with bleeding into organs and skin (purpura). – Fever and chills; vomiting; diarrhea; joint, muscle, abdominal or chest pain; tachypnea; cold hands and feet – Meningococcemia can be fatal.
69.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Neurologic disorders – Child seizures Fever (common cause) Epilepsy Toxins Drugs Metabolic disturbances (check for hypoglycemia) Trauma Intracerebral hemorrhage Tumors
70.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Neurologic disorders (continued) – Febrile seizures: related to rate fever increases; short in duration with limited postictal state – Do not bundle febrile child in blankets; do not allow child to become chilled. • What does mnemonic AEIOU-TIPS stand for?
71.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Neurologic disorders (continued) – Hydrocephalus: imbalance between formation and outflow or absorption of cerebrospinal fluid. – Large head with bulging fontanelles and separation of cranial sutures – Once fontanelles are closed, increased intracranial pressure (ICP) can lead to headaches, changes in vision, cognitive difficulties, decreased responsiveness, and respiratory arrest. – Treat with ventriculostomy shunt.
72.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Diabetes – In children, usually insulin-dependent diabetes mellitus (IDDM), Type II increasing – Death from complications of undiagnosed diabetes Diabetic ketoacidosis (DKA) Cerebral edema from untreated or poorly treated diabetes Hypoglycemia
73.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Diabetes (continued) – Signs and symptoms Altered mental status: Obtain blood glucose level in all patients with altered mental status. Severe, persistent diaper rash; yeast organisms Lethargy or malaise Weight loss Thirst Frequent urination
74.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Diabetes (continued) – Look for severe dehydration, presence of ketone odor, Kussmaul’s respirations, vomiting, decreased level of responsiveness. – Hypoglycemia: patients being treated for diabetes; occurs suddenly with irritability; behavioral changes; pale, cool skin; seizures; decreased level of responsiveness • What are the signs of dehydration for children?
75.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Gastrointestinal disorders – Gastroenteritis; vomiting and diarrhea – Constipation common – Vomiting and diarrhea are often due to viruses and foodborne illness. – Abdominal pain: appendicitis, urinary tract infection, DKA, hernias, bowel obstruction, intussusception, volvulus, pyloric stenosis, swallowed foreign bodies
76.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Eye, ear, nose, and throat disorders – Conjunctivitis, styes, chalazia – Orbital and periorbital cellulitis―medical emergencies – Foreign bodies in eyes, ears, nose – Otitis externa, otitis media often common – Epistaxis common; usually anterior site – Pharyngitis
77.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Behavioral emergencies – Depression, mood disorders, substance abuse and addiction, anxiety disorders, eating disorders, impulse control disorders – Risk of suicide increases in adolescents. – Your safety can be jeopardized by a child or adolescent with behavioral emergency, just as it can be by adult patient.
78.
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2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Toxicologic emergencies – Curiosity – Underdeveloped sense of taste – Inability to recognize consequences of behavior – Poor supervision – Poor childproofing – Drug and alcohol abuse – Suicide attempts
79.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Pediatric Medical Emergencies • Toxicologic emergencies (continued) – Constant awareness of mental status, airway, breathing – Pediatric dosage of activated charcoal is 1 gram/kg, with minimum of 15 grams; follow your protocols or advice of poison control or online medical direction. Adult dose is usually 25–50 g.
80.
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2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (1 of 13) • Pediatric mechanisms of injury (MOI) – Most common MOI in pediatric patients due to blunt forces – In motor vehicle collisions (MVCs), high index of suspicion for multiple injuries (head and neck) – Restrained pediatric occupants can suffer serious injury from airbag deployment and seat belts.
81.
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2012 Pearson Education, Inc. All Rights Reserved. Table 44-10 (1 of 2) 2011 Guidelines for Field Triage of Injured Patients Vital Signs and Level of Responsiveness Glasgow Coma Scale < 14 or Systolic blood pressure < 90 mmHg or Respiratory rate < 10 or > 29 breaths per minute (< 20 in infant < one year old) Anatomy of Injury All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee Chest wall instability or deformity (e.g., flail chest) Two or more proximal long-bone fractures Crushed, degloved, or mangled extremity Amputation proximal to wrist or ankle Pelvic fracture Open or depressed skull fracture Paralysis Mechanism of Injury and Evidence of High-Energy Impact Falls Adults > 20 ft (1 story = 10 ft) Children > 10 ft or two to three times patient’s height High-risk auto crash Intrusion > 12 in. occupant site; > 18 in. any site Ejection (partial or complete) from automobile Death in same passenger compartment Vehicle telemetry data consistent with high risk of injury Auto versus pedestrian/bicyclist thrown, run over, or with > 20 mph impact Motorcycle crash > 20 mph
82.
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2012 Pearson Education, Inc. All Rights Reserved. Table 44-10 (2 of 2) 2011 Guidelines for Field Triage of Injured Patients Special Patient or System Considerations Age Risk of injury death increases after age 55 years Children should be preferentially triaged to pediatric-capable trauma centers Anticoagulation and bleeding disorders Burns Without other trauma: triage to burn facility With trauma mechanism: triage to trauma center Time-sensitive extremity injury End-stage renal disease requiring dialysis Pregnancy > 20 weeks EMS provider judgment
83.
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2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (2 of 13) • Pediatric mechanisms of injury (MOI) (continued) – Injuries of child struck by vehicle depend on speed of vehicle and patient’s height in relation to vehicle. – High-speed impact: head, neck, multiple internal organ injuries
84.
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2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (3 of 13) • Assessment and management – Three most common causes of pediatric trauma death following injury: hypoxia, massive hemorrhage, traumatic brain injury – In pediatric patient with suspected cervical-spine trauma, maintain head in neutral position, placing folded towel or blanket under shoulders. – If child does not have gag reflex, insert oropharyngeal airway.
85.
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2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (4 of 13) • Assessment and management (continued) – Prehospital endotracheal intubation in pediatric patients associated with worse outcomes – Traumatic brain injury, shock, and chest trauma can result in need for assisted ventilations. – Use supplemental oxygen; adjust rate and depth according to patient’s size. – Hyperventilation is a common mistake in trauma patients; can worsen cerebral edema, impair cardiac output.
86.
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2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (5 of 13) • Assessment and management (continued) – Control external hemorrhage; high index of suspicion for internal bleeding. – Keep patient warm. – Monitor mental status, vital signs, signs of perfusion to detect emerging shock. – Bradycardia and tachycardia are concerns. – Capillary refill reliable sign of perfusion in pediatric patients. – If shock is suspected, infuse IV/IO fluids in a bolus of 20 ml/kg; unstable/critical patient.
87.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Figure 44-7 The Rule of Nines, used to calculate the percent of body surface involved in burns, is altered in infants and children to account for their proportionately larger heads.
88.
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2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (6 of 13) • Considerations in spinal motion restriction – Car seat used to assist in manual stabilization of spine during extrication; seat and child removed from vehicle as unit, then transfer child to immobilization device – Padding may be required under shoulders to properly align cervical spine. – Child’s smaller size increases need for padding along sides of body to prevent him from sliding from side to side on backboard.
89.
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2012 Pearson Education, Inc. All Rights Reserved. Figure 44-8 Indications of child abuse: (A) burns to the feet caused by dunking the child’s feet in hot water (© SPL/Science Source) (B) bruising resulting from physical abuse. (© Biophoto Associates/Science Source) (A) (B)
90.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (7 of 13) • Burns – Children have thin skin; can be burned at much lower temperature, shorter duration of exposure to heat than adults – Many accidental childhood burns can be prevented through safety measures. – One in five burns in children is a result of child abuse or child neglect; burn patterns should increase your suspicion.
91.
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2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (8 of 13) • Drowning – Primary respiratory impairment resulting from submersion in liquid medium – Incidence higher in toddlers and in adolescent males. Most toddler drownings occur in bathtubs and swimming pools. Risk-taking behavior and alcohol implicated in adolescent male group.
92.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (9 of 13) • Drowning (continued) – Drowning: asphyxia resulting in hypoxia and acidosis – Most children who survive drowning rescued within 2 minutes of submersion. – Death occurs due to: asphyxia, cardiac arrest, acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS).
93.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (10 of 13) • Drowning (continued) – If patient still in water, perform rescue only if it is safe to do so. – Otherwise, await trained water rescue personnel. – Remove from water as quickly as possible. – If unresponsive, begin chest compressions according to CPR guidelines for patient’s age. – Transport all patients who have been submerged in water.
94.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (11 of 13) • Drowning (continued) – For patients in cardiac arrest, begin chest compressions immediately. – Consider airway management, ventilation early. – Follow your protocols regarding measures to treat hypothermia in drowning patients.
95.
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2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (12 of 13) • Child abuse and neglect – Child abuse: improper, intentional, or excessive action that causes injury or harm to child – Child neglect: inadequate provision of attention or respect to person entitled to it – In many states, you are considered mandatory reporter of suspected child abuse or neglect.
96.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Shock and Trauma in Pediatric Patients (13 of 13) • Child abuse and neglect (continued) – You are ethically obligated to report suspicions. – Reporting depends on your protocols and laws in your jurisdiction. – First priorities: scene safety, providing medical treatment for child – Carefully document all pertinent information.
97.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Table 44-11 Documenting Suspected Child Abuse or Neglect Document objectively. Do not make assumptions or draw conclusions. For example, you could document that the patient stated he was struck with a belt buckle or that the patient has a three-inch by two-inch U-shaped bruise on his back, but you cannot state that (in your opinion) the patient was beaten with a belt buckle. Objectively document and precisely describe all injuries by their appearance and locations. Make drawings if possible. Place in quotation marks any relevant statements made by the patient, witnesses, or caregivers. Document the conditions of the surroundings. Document relevant aspects of the child’s appearance, such as what he was wearing, for example, if he was found outside in cold weather but not wearing a coat, or if the child is unkempt or appears thin or emaciated. Document the behavior of the child and caregivers.
98.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Chapter Summary (1 of 6) • Pediatric patients not only smaller but also have anatomic, physiological, psychosocial differences you must consider in assessment and management of emergencies. • Epidemiology of injury and illness different in pediatric age group.
99.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Chapter Summary (2 of 6) • Keys to successfully managing pediatric calls: – Knowledge of pediatric differences – Use of equipment designed for pediatric patients – Ability to maintain composure
100.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Chapter Summary (3 of 6) • Key differences in pediatric patients: – Airway and airway management techniques – Increased susceptibility to hypothermia and dehydration – Subtle signs and symptoms of shock despite significant blood loss
101.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Chapter Summary (4 of 6) • More vulnerable to effects of infectious illness; can lead to airway obstruction or respiratory distress, respiratory failure, or respiratory arrest. • Hypoxia is the leading cause of cardiac arrest in pediatric patients.
102.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Chapter Summary (5 of 6) • SIDS and ALTE affect infant age group. – Related signs can mimic indications of possible child abuse. – Document scene carefully as potential crime scene without implying that parents in any way at fault for situation. – Recognize, document, and report suspected child abuse and neglect.
103.
Copyright © 2017,
2012 Pearson Education, Inc. All Rights Reserved. Chapter Summary (6 of 6) • Pediatric patients can receive different patterns of trauma than adults subjected to same mechanisms because of anatomical differences. • Blunt mechanisms most common in pediatric population, likely to produce multisystem trauma. • Whenever possible, transport critically ill or injured pediatric patients to facility capable of specialized pediatric care.
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