Angel

CBT537: Pediatric Emergencies 2010

© 2010 Seattle / King County EMS

Introduction
• Children's bodies respond to significant
injury and shock differently than adults.

• These differences may be subtle and
difficult to recognize.

EMS providers must recognize these
EMS providers must recognize these
differences in order to provide the best
differences in order to provide the best
possible care for an ill or injured child.
possible care for an ill or injured child.


Practical Skills
To receive CBT or OTEP credit for this course
a trained skills evaluator must evaluate your
ability to perform the following hands-on
practical skills:
• Patient assessment of using the Pediatric
Assessment Triangle (medical and trauma)
• Backboarding
• CPR/FBAO skills for pediatric patients
• Oxygen therapy and ventilation with a BVM


Terms
cyanosis — A condition where the skin, lips, nail beds
and mucous membranes appears bluish in color due to
insufficient air exchange and low levels of oxygen in the
blood.

compensated shock — An early stage of shock in
which the body is able to compensate for inadequate
tissue perfusion. It is characterized by sustained
tachycardia, decreased skin perfusion and subtle
changes in mental status.


Terms, continued
decompensated shock — A later stage of shock in
which the body’s compensatory mechanisms break
down.

fontenelle — Areas where the cranial bones of an infant
have yet to grow together creating soft spots on the
head.

hypotension — Blood pressure that is lower than the
normal range. A systolic blood pressure below 70 + (2 x
age in years) is considered hypotension in children.


Terms, continued
occiput — Base of the back of the head.

perfusion — Circulation of blood within an organ or
tissue in adequate amounts to meet cellular needs.

nasal flaring — As a child breathes out, the nostrils
widen. Seen in infants and toddlers; an indicator of
increased work of breathing.


Terms, continued
NOT SICK — Someone who appears
physiologically stable as
indicated by adequate
respirations, pulse, mental
status, skin signs and an
appropriate body position.

Other terms that mean NOT SICK include
Other terms that mean NOT SICK include
non-critical, non-urgent or stable.
non-critical, non-urgent or stable.


Terms, continued
SICK — Someone who appears
physiologically unstable as
indicated by clinical indicators.

Other terms that mean SICK include critical,
Other terms that mean SICK include critical,
urgent or unstable.
urgent or unstable.


Terms, continued
shock — A condition that is caused by inadequate
tissue perfusion. It usually develops when the
circulatory system is not able to deliver sufficient blood
and oxygen to the body organs.

sniffing position — A position of the head assumed by a
patient who is attempting to maximally open his or her
airway when an obstruction is present.


New Terms
meningitis — An inflammation of the meninges that
covers the brain and spinal cord.

postictal — An altered state of consciousness that
occurs after experiencing a seizure. Postical states
usually lasts between 5 and 30 minutes and are
characterized by confusion, drowsiness and nausea.

respiratory failure — Occurs when a child cannot
compensate for inadequate oxygenation and circulatory
and respiratory systems begin to collapse.


New Terms, continued
respiratory distress — Occurs when a child is able to
maintain adequate oxygenation of the blood but only by
increasing work of breathing.

retractions — A visible sinking-in of the soft tissues in
the chest wall or neck muscles seen during respiratory
distress.

sustained tachycardia — A persistently fast heart rate
of 100 –120 or greater depending on the clinical setting.


Anatomical Differences
A child’s anatomy differs in four significant
ways from an adult’s. They are:

• Smaller airways
• Less blood volume
• Bigger heads
• Vulnerable internal organs


Anatomical Differences, cont'd
• Large tongue in relation to
smaller airway
smaller airway a small oropharynx
• Diameter of the trachea is
smaller
• Trachea is not rigid and
will collapse easily
• Back of the head is
rounder and requires
careful positioning to keep
airway open


• Relatively smaller blood
smaller airway
smaller airway volume
• Approximately 70 cc of
less blood volume blood for every 1kg (2 lbs)
less blood volume
of body weight
• A 20 lb child has about
700cc of blood—about the
volume of a medium sized
soda cup


• Head size is proportionally
smaller airway
smaller airway larger
• Prominent occiput and a
less blood volume relatively straight cervical
less blood volume
spine
• Neck and associated
bigger heads
bigger heads support structures aren’t
well developed
• Infants and small children
are prone to falling
because they are top
heavy


• Internal organs are not
smaller airway
smaller airway well protected
• Soft bones and cartilage
less blood volume and lack of fat in the rib
less blood volume
cage make internal
organs susceptible to
bigger heads
bigger heads significant internal injuries
• Injury can occur with very
internal organs
internal organs little mechanism or
obvious signs


Development Considerations
Infant: 1 to 12 months
• Active extremity movement
• Tracks object with eyes
• Obstruction of the nose may cause
respiratory distress
• Separation anxiety later in this period
• Provide sensory comfort such as a warm
stethoscope
• Explain procedures in very simple terms


Development Considerations, ii
Toddler: 1 to 3 years
• Approach slowly & limit physical contact
• Most have stranger anxiety
• Sit down or squat next to and use a quiet
voice
• Not good at describing or localizing pain
• Use play and distraction objects
• Have caregiver hold
• Ask only yes/no questions
• Get history from parent

Development Considerations, iii
Preschool Age: 3 to 5 years
• Explain procedures in simple terms
• Use games or distractions
• Set limits on behaviors
• Praise good behavior
• Offer a stuffed animal or toy to hold
• Do not allow to handle equipment


Development Considerations, iv
School Age: 6 to 12 years
• Speak directly to the child
• Be careful not to offer too much information
• Explain procedures immediately before
carrying them out
• Don’t negotiate unless the child really has a
choice
• Keep conversation with child to a minimum


Development Considerations, v
Adolescent: 12 to 15 years
• Explain what you are doing and why
• Show respect
• Get history from patient if possible
• Respect independence; address directly
• Allow parents to be involved in examination
if patient wishes
• Consider asking questions about sexual
activity, drug/alcohol use privately


SICK
• One you believe is physiologically unstable
based on observable clinical indicators.
• He or she has significant abnormality in
appearance, work of breathing or circulation
to the skin.
• A SICK patient requires immediate and
aggressive BLS and ALS care.


SICK, continued
• You must recognize the SICK child within the
first minute of contact.

Much of the information you need to make a
Much of the information you need to make a
decision can be obtained without touching
decision can be obtained without touching
the patient.
the patient.


NOT SICK
• One you believe is physiologically stable.
• He or she has no significant abnormality in
appearance, work of breathing or
circulation to the skin.
• They do not need immediate ALS
intervention--but may require BLS care or
an ALS evaluation.


Pediatric Assessment Triangle
There are three elements that you need to
assess in a pediatric patient in order to
determine SICK or NOT SICK:
• Appearance
• Work of breathing
• Circulation to the skin

These three clinical indicators reflect the
These three clinical indicators reflect the
overall status of a child’s cardiovascular,
overall status of a child’s cardiovascular,
respiratory and neurologic systems.
respiratory and neurologic systems.

PAT, continued
• Alertness
airway
airway • Distractibility
• Consolability
• Eye contact
• Speech/cry
• Spontaneous motor
activity
• Color


PAT, continued
• Abnormal position
airway
airway • Abnormal breath sounds
• Retractions
• Nasal flaring
work of breathing
work of breathing


PAT, continued
• Color
airway
airway • Temperature
• Capillary refill time
• Pulse quality
work of breathing
work of breathing

circulation
circulation


Respiratory Emergencies
• Respiratory distress is a state where a child
is able to maintain adequate oxygenation of
the blood, but only by increasing his or her
work of breathing.
• Respiratory failure occurs when a child
cannot compensate for inadequate
oxygenation and the circulatory and
respiratory systems begin to collapse.


Seizures
Seizures may be caused by:
• Infection
• Head trauma
• Epilepsy
• Electrolyte imbalance
• Hypoglycemia
• Toxic ingestion or exposure
• Birth injury


Meningitis
Signs and symptoms can include:
• Altered LOC
• Fever
• Seizures
• Stiff neck
• Pain on moving of the head
• Small, red spots or purplish rash
• Irritability in infants
• Bulging fontenelle

Poisoning
Common sources of poisons include:
• Alcohol
• Pills
• Cleaning products
• Houseplants
• Vitamins


Trauma
• Use appearance, work of breathing and
circulation to the skin in your assessment.
• Mechanism of injury may also play a
factor when deciding whether the child is
SICK or NOT SICK.


Drowning
• The most important factors in drowning
are the duration and severity of hypoxia.
• Restoring the ABCs is vital.
• Hypothermia can occur in cold water
settings.


Burns
• Check for possible involvement of the
airway.
• Make a quick estimate of the burned
body surface area.
• Take care to avoid further contamination
of burn injuries by wearing gloves and
carefully dressing the wounds.


Abuse and Neglect
General indicators of abuse include:
• Passive and withdrawn behavior
• Bruises on soft parts of body
• Burns in patterns or unusual locations
• Facial or head injuries
• Multiple injuries at various stages of
healing
• Poor hygiene (physical, dental) or poor
nutrition
• Drug/alcohol abuse

Injury Patterns—Accidental
• Injury usually on bony prominence
• One injury or set of injuries usually occurs
with resolution rather than repeatedly the
same injury
• Lacerations more common
• One body plane usually affected


Injury Patterns—Intentional
• Injury usually on soft parts of body
• Pattern injury (finger, bite marks, cord and
strap marks)
• Injuries at various stages of healing
• Lacerations uncommon
• Injuries on multiple body planes


Pediatric Shock
• Never wait for a drop in blood pressure to begin
treating for shock.
• Children maintain blood pressure by increasing their
heart rate and vasoconstriction --- even with a
significant loss of blood volume. This means that
blood pressure does not drop until much later in the
progression of shock.
• A child can lose up to one third of blood volume
before a significant drop in blood pressure occurs.
• Use appearance and circulation to the skin to assess
for shock.


Signs of Shock—Early
• sustained tachycardia **
• delayed capillary refill > 2 seconds
• tachypnea
• anxiousness, combativeness, agitation
• peripheral constriction, cold clammy
extremities

** May be the only suggestive finding.


Signs of Shock—Late
• weak or absent peripheral pulses
• decreased LOC – unconsciousness
• hypotension (a very late and ominous sign)


Airway Management
• You may need to position the head in a neutral
position with a towel under the shoulders. Take care
to not flex or extend the head, which can easily
collapse the trachea.
• Use the head tilt-chin lift maneuver when there is no
trauma involved.
• Use the jaw-thrust maneuver in cases where trauma
was involved.
• Be prepared to suction the airway to remove foreign
objects or fluids.
• While maintaining an open airway, take no more than
10 seconds to look, listen and feel for breathing


Choking—Infant
• Obstructions from a foreign body range from
mild to severe.
• When an airway obstruction is mild, the infant
should be able to cough and make sounds.
• Do not interfere with these efforts. If an
obstruction is severe and the infant is
responsive, perform the following steps to
relieve the obstruction.


Choking—Infant, continued
Responsive Infant – Severe Obstruction
1. Kneel or sit with the infant in your lap and bare the
infant’s chest.
2. Hold the infant prone with the head slightly lower than
the chest. Support it with your arm. Support the head
with your hand.
3. Deliver up to 5 backslaps with the heel of your hand,
between the shoulder blades.
4. Place the infant face up supporting it with your arm.
5. Deliver up to 5 quick chest thrusts just below the
nipple line.

Do steps 3 – 5 repeatedly until the object is expelled or
the infant becomes unresponsive.

Choking—Infant, continued
Unresponsive Infant – Severe Obstruction
1. Open the airway.
2. Remove the object only if you see it.
(No blind finger sweeps)
3. Begin CPR with an airway check.
4. Look for the obstruction each time you open
the airway to ventilate.


Choking—Child
• Important to recognize an airway obstruction
quickly and distinguish it from a seizure,
syncope, cardiac arrest or overdose.
• When an airway obstruction is mild, a victim
should be able to talk, cough or make
sounds.
• Do not intervene when an obstruction
appears to be mild.


Choking—Child, continued
Responsive Child – Severe Obstruction
(age 1-adolescent [12-14])

• If the obstruction is severe and the child is
responsive, perform abdominal thrusts.


Choking—Child, continued
Unresponsive Child – Severe Obstruction
If the obstruction is severe and the child is
unresponsive, perform the same procedure as for
an adult:
1. Open the airway.
2. Remove the object if you see it.
(No blind finger sweeps)
3. Begin CPR with an airway check.
4. Look for the obstruction each time you open
the airway to ventilate.

Oxygen Therapy
• Every child with a respiratory emergency or
significant trauma should receive high flow oxygen.
Use the appearance, work or breathing and
circulation to the skin as a guide for determining a
child’s oxygen needs and which delivery device to
use. You may need to assist respirations.

Delivery device options are:
• Blow-by oxygen
• Pediatric non-rebreathing mask (NRM)
• Bag-valve mask (BVM)


Oxygen Therapy, continued
• Healthcare providers often deliver excessive
ventilation during CPR, particularly when an
advanced airway is in place.
• Excessive ventilation is detrimental because
it impedes venous return and therefore
decreases cardiac output, cerebral blood flow
and coronary perfusion. It also increases the
risk of regurgitation and aspiration.
• Do not over-ventilate.


Treatment—Seizures
• Assess for adequate respirations
• Maintain an open airway
• Prepare to suction and ensure proper positioning
• Other care may include: Protecting the actively
seizing patient from trauma, administering oxygen
therapy, assisting ventilations, monitoring vital signs,
cooling measures, ALS response

Recovery Position
• For children who are actively seizing or in a postictal
state, consider using the recovery position. This will
help prevent the tongue from blocking the airway.


Treatment—Drowning
1. Open the airway and begin rescue
breathing as soon as possible.
2. Next, begin chest compressions on a victim
with no pulse.
3. If vomiting occurs, tilt the victim’s head to
the side and remove the vomitus using your
finger or suction.*

*If there is no potential for c-spine injury.


Summary
• The anatomic differences between adult and
children are smaller airways, less blood
volume, bigger heads and vulnerable internal
organs.
• The 3 elements of the Pediatric Assessment
Triangle are appearance, work of breathing
and circulation to the skin.


Summary, continued
The 7 aspects of the appearance element of
the Pediatric Assessment Triangle are:
• Alertness
• Distractibility
• Consolability
• Eye contact
• Speech/cry
• Spontaneous motor activity
• Color


Summary, continued
• The SICK child is one who you believe is
physiologically unstable based on observable
clinical indicators.
• Physiologic instability means that you see a
significant abnormality in either appearance,
work of breathing or circulation to the skin.


Summary, continued
• The NOT SICK child is one who you believe
is physiologically stable and has no
significant abnormality in appearance, work
of breathing or circulation to the skin.


Summary, continued
The appearance of a SICK child can include:
• Motionless
• Mottled, dusky
• Cyanotic
• Fixed gaze
• Limp and listless
• Weak cry
• Hoarse, stridor


Summary, continued
The appearance of a NOT SICK child can
include:
• Restless and • Screaming
agitated • Consolable by
• Alert caregiver
• Interactive • Maintains good eye
• Attentive contact
• Playful, active • Good muscle tone,
pink skin color


Summary, continued
Indicators of increased work of breathing
include:

• Abnormal position
• Abnormal breath sounds
• Retractions
• Nasal flaring


Summary, continued
The overall status of the circulatory system is
reflected in circulation to the skin.

Skin signs include:

• Color
• Temperature
• Capillary refill time
• Pulse quality


Summary, continued
Signs of early shock include:
• Sustained tachycardia
• Delayed capillary refill > 2 seconds
• Tachypnea
• Anxiousness, combativeness,
agitation
• Peripheral constriction, cold clammy
extremities


Summary, continued
Signs of late shock include:
• Weak or absent peripheral pulses
• Decreased LOC – unconsciousness
• Hypotension (a very late and
ominous sign)


Summary, continued
• Do not intervene when an airway obstruction
appears to be mild.
• In children you may need to position the
head in a neutral position with a towel under
shoulders.


Summary, continued
For a responsive infant with a severe FBAO:
• Give 5 backslaps, 5 chest thrusts, repeat

For a responsive child with a severe FBAO:
•Give abdominal thrusts


Summary, continued
Unresponsive Infant or Child—Severe
Obstruction:

1. Open the airway.
2. Remove the object if you see it. (No
blind finger sweeps.)
3. Begin CPR.
4. Each time you open the airway, look for
the obstruction in the back of the throat.


Resources

• Chapters 31 and 32 in Emergency Care
and Transportation of the Sick and
Injured, 9th edition (AAOS).


Questions
EMS Online
Guidelines and Standing Orders
http://www.emsonline.net/downloads.asp

Tracey White
Training Division Manager
Email support: help@emsonline.net

Dr. Mickey Eisenberg
Medical Director
Ask the Doc: http://www.emsonline.net/doc.asp


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