(1) Infants and young children have unique developmental, anatomical, and physiological considerations that impact emergency care. (2) Key focus areas include maintaining the airway, handling separation from parents sensitively, and addressing fears of medical procedures. (3) Common illnesses and injuries seen in pediatrics include respiratory distress, seizures, shock, trauma, and abuse/neglect - all of which require prompt stabilization and transport.

1. Infants and Children

2. Developmental Concerns
Infants
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Newborns and infants – (Birth to 1 yr)
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Minimal stranger anxiety
Do not like to be separated from parents
Do not tolerate NRBs
Poor thermoregulators = Need to be kept
warm
Breathing rate best obtained at a distance
• Note -Chest rise –Color –Level of
activity
Examine heart and lungs 1st – Head last
• Builds confidence
• Allows optimal assessment before
child becomes agitated

3. Developmental Concerns
Toddlers
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Toddlers- (1 yr-3 yrs)
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Do not like to be touched
Do not like being separated
from parents
Do not like having clothing
removed
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Do not tolerate NRB’s
Children interpret illness as
punishment
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Remove – Examine - Replace
Assure the pt they have not
been “bad”
Afraid of needles
Fear of pain
Trunk to head assessment
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Builds confidence
Done before child becomes
agitated

4. Developmental Concerns
Preschool
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Preschool- (3 yrs-6yrs)
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Do not like to be touched
Do not like being separated
from parents
Do not like to have clothing
removed
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-Remove – Assess Replace
Do not tolerate NRB’s
Assure child they were not
“bad”
Afraid of blood
Fear of pain
Fear of permanent injury
Modest

5. Developmental Concerns
Adolescents
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School age- (6 yrs- 12 yrs)
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Afraid of blood
Fear of pain
Fear of permanent injury
Modest
Fear if disfigurement
Adolescent- (12 yrs-18 yrs)
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Fear of permanent injury
Modest
Fear of disfigurement
Treat as adults
May desire to be assessed
privately
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Away from
parents/administrators/friends

6. Anatomical/Physiological Concerns: Airway
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Small airways throughout the resp system
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Tongue is large in relations to small mandible
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DO NOT hyperextend
Infants are obligate nose breathers
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Can be significant airway complication in unresponsive child
Positioning airway is different
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Easily blocked by secretions and swelling
Suctioning the nasopharynx can improve respirations
Children can compensate well for short periods of time
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Increased breathing rate and effort of breathing
Compensation rapidly followed by decompensation
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Rapid respiratory muscle fatigue
General fatigue of the infant

8. Airway Techniques
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Airway opening
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Head tilt chin lift = no
trauma
Modified jaw thrust =
trauma
Do not hyperextend
Infants below 1 y/o
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“sniffing position”
Small children 1-8 yrs
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Extend but do not
hyperextend

9. Another type of sniffing position…

10. Suctioning
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Suctioning
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Blood, vomit, small particulate
matter from airway
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Nasopharynx
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Rigid suction catheter
Insert only as far back as
you can see
Pressure less than 300 mmHg
Should not exceed 100 mmHg
in newborns
Suction for 15 seconds or less
Soft suction catheter
Suction for 15 seconds or less
If appropriate, hyperventilate
the pt before and after
suctioning
If airway is full of secretions
that cannot be easily cleared
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Log roll pt onto side

11. Airway Adjuncts
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Adjuncts
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Oral airways
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Not for initial artificial
ventilation
Should not have a gag
reflex
Size as normal
Use tongue depressor
Insert tongue blade to
base of tongue
• Push down against
tongue while lifting
upwards
• Insert OPA directly in
without rotation
Nasal airways
• Not for initial artificial
ventilation
• Size as normal
• Insert as normal
• Contraindicated in trauma
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12. Oxygen Deliver
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Oxygen Delivery
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Nonrebreathers
Blow By
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Hold O2 tubing 2” from face
Insert tubing into a paper cup or
stuffed animal
Artificial Ventilation
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Mask/bag size determined by
age/size of pt
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Consider trauma
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-Neonatal – Pediatric - Child
Modified jaw thrust
Manual in line stabilization
Mouth to mask ventilation
Use of BVM
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Squeeze bag slowly and evenly
allowing chest rise
Rate at 20 breaths per minute
Provide O2 at 100% using an O2
reservoir

13. Infants and Children
Assessment
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Pediatric Assessment Triangle
General impression can be
obtained from overall appearance
(Well v. sick)
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Mental Status
Effort of breathing
Color
Quality of cry/speech
Interaction to parents/environment
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Normal behavior based on age
Playing
Moving around
Attentive v non attentive
Eye contact
Recognized parents
Responds to parents calling
Emotional state
Response to the EMT
Tone/body position

14. Approach to Evaluation
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Begin from across the room
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MOI
Scene size up
General impression
Respiratory assessment
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Note chest expansion/symmetry
Effort of breathing
Nasal flaring
Stridor, crowing, noisy
Retractions
Grunting
Respiratory rate
Perfusion assessment
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Skin color

15. Approach to Evaluation
“Hands on”
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“Hands on” Approach
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Assess breath sounds
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Assess circulation
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Present
Absent
Stridor or wheezing
Assess brachial or femoral
pulse
Assess peripheral pulse
Assess capillary refill
Assess BP in children 3 y/o
and older
Assess skin color,
temperature, moisture
Detailed physical exam
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Trunk to head approach
Situation and age dependant
Should help reduce infant/child
anxiety

16. Common Problems
Partial Airway Obstruction
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Partial Airway Obstruction
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S/S
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Infants who are alert and sitting
Stridor, crowing, noisy
Retractions on inspiration
Pink
Good peripheral perfusion
Still alert, not unconscious
Emergency care
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Allow position of comfort
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Assist younger child to sit up
Do not lay down
May sit on parents lap
Offer O2
Transport
Do not agitate child
Limited exam

17. Common Problems
Complete Airway Obstruction
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Complete Airway Obstruction
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S/S
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No crying/speaking and cyanosis
Childs cough becomes ineffective
Increased resp difficulty with stridor
Loss of consciousness
AMS
Emergent clearing of airway
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-Total blockage of airway -ORPartial obstruction with -AMS – Cyanosis
Infant procedures
Child procedures
Attempt artificial ventilation with BVM and good seal

18. Airway Obstructions
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Complete obstructions
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Infants less than 1 y/o
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Back blows/chest thrusts
Visual foreign body removal
Children 1 y/o+
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Abdominal thrusts
Visual foreign body removal

19. Upper v Lower Respiratory Presentations
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Upper Airway Obstruction
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Lower Airway Disease
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Stridor on inspiration
Wheezing and breathing
effort on exhalation
Rapid breathing without
stridor
Complete Airway
Obstruction
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No crying
No speaking
Cyanosis
No coughing

20. S/S of Resp Compromise
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S/S of Early Respiratory Distress
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Nasal flaring
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Retractions
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Intercostal, Supraclavicular, Subcostal
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Adnominal, Neck
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Stridor
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Audible wheezing
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Grunting
S/S of Progressive Respiratory Distress
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Rate above 60 breaths per minute
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Cyanosis
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Decreased muscle tone
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Severe use of accessory muscles
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Poor peripheral perfusion
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AMS
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Grunting
S/S of Respiratory Arrest
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Rate less than 10 breaths per minute
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Limp/flaccid muscle tone
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Unconscious
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Slow, absent heart rate
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Weak, absent distal pulses

21. Treatment of Resp Compromise
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Emergency Care of Respiratory Compromise
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O2
O2 and Assist ventilation is severe distress
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Resp distress and AMS
Cyanosis with O2
Resp distress with poor muscle tone
Resp failure
Provide O2 and ventilate with Resp arrest

22. Common Problems
Seizures
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General comments:
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Assessment
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Assess for injuries incurred by
seizure activity
Caused by
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Rarely life threatening in children
with a Hx
However, consider any seizure to
be life threatening
May be brief or prolonged
Although they can be brief there
could be a more serious
underlying problem
Fevers – Infections – Trauma –
Hypoglycemia –Poisoning –
Hypoxia – Idiopathic
Hx of seizures
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Has the child has prior seizures?
If yes, is this the normal seizure
pattern?
Has the child taken any anti
seizure medications?

23. Treatment of Seizures
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Assure airway position and patency
If no C-spine trauma place pt on side
Have suction ready
Provide O2
Treat S/S of respiratory compromise if found
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Inadequate breathing and AMS may follow a
seizure
Transport

24. Common Problems
Altered Mental Status
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Caused by
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Hypoglycemia
Poisoning
Seizure
Infection
Head trauma
Hypoxia
Hypoperfusion
Emergency Care
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Assure patency of airways
Be prepared to artificially ventilate/suction
Transport

25. Common Problems
Poisoning
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Poisoning
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Common reason for EMS activation
Identify suspected container
through Hx
Bring container to hospital if
possible
Emergency Care
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Responsive Pt
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Contact med control
Consider activated charcoal
O2
Transport
Monitor pt for
AMS/unresponsiveness
Unresponsive Pt
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Assure patency of airway
Be prepared to artificially ventilate
O2
Call med control
Transport
Rule out trauma as cause of AMS

26. Common Problems
Fever
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Fever
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General comments:
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Many causes, rarely life
threatening
Severe case is
meningitis
Fever with a rash is a
significant finding
May precipitate a febrile
seizure
Emergency Care
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Transport
Be prepared for a
seizure

27. Common Problems
Shock
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Shock
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General comments:
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Common Causes:
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Diarrhea and dehydration
Trauma
Vomiting
Blood loss
Infection
Abd injuries
Less common causes:
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Rarely a primary cardiac event
Allergic reactions
Poisoning
Cardiac
S/S
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Rapid resp rate
Pale, cool, clammy skin
Weak/absent peripheral pulses
Delayed capillary refill
Decreased urine output
ALOC/AMS
Absence of tears even when crying

28. Treatment of Shock
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Assure airway/O2
Be prepared to artificially ventilate
Manage bleeding if present
Place pt in shock position
Keep warm
IMMEDIATE transport
Detailed exam en route if time permits

29. Common Problems
Water Related Accidents
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Near Drowning
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Ventilation is TOP priority
Consider
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possible trauma
hypothermia
possible ingestion
(alcohol, etc)
Protect airway
Suction if necessary
Secondary Drowning
Syndrome
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Minutes to hours after the
event
Deteriorate after breathing
normally
Therefore, transport ALL
near drowning pts

30. Common Problems
SIDS
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Sudden Infant Death Syndrome
(SIDS)
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S/S
• Sudden death of infant
within 1st year
• Causes are many and not
well understood
• Most commonly found
during early morning
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Emergency Care
• Try to resuscitate unless
rigor mortis
• Parents will be in distress
• Avoid comments that may
place blame

31. Infants and Children
Trauma
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Injuries are the #1 COD in infants/children
Blunt injury is mot common
Pattern of injury if different from adults
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Motor Vehicle Passengers
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Struck with riding bicycle
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Injuries to head/neck
Burns
Sport injuries
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Head, Spine, Abd injury
Falls from heights
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Unrestrained = Head/Neck injuries
Restrained= Abdomen and spinal injuries
Head/neck
Child abuse

32. Infants and Children
Trauma: Specific Body Regions
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Head
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Chest
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Soft very pliable ribs
May have injuries without external signs
Abdomen
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Maintain airway via modified jaw thrust
More likely to sustain head injuries
S/S of shock with head injury suggest other injuries
Respiratory arrest is common secondary to head injury
Common S/S = Nausea/Vomiting
Major airway complication = Tongue
More common in children than adults
Often a source of hidden injuries
ALWAYS consider this in multi-system trauma pt who is deteriorating without external
S/S
Be aware of complications of gastric distention
Extremities
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Manage in the same manner as adults

33. Other Considerations
PASG, Burns
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Pneumatic Anti Shock Garments
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Use ONLY if child fits
Do not inflate abd compartment
Indication
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S/S hypoperfusion
S/S of pelvic instability
Criticality of burns
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Cover with sterile dressing
Possible transport to a burn center per protocol

34. Care of the traumatically injured
pediatric
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Assure airway position and patency
Use modified jaw thrust
O2
Assist ventilation in resp distress
Ventilate with BVM in resp arrest
Immobilization
IMMEDIATE transport

35. Abuse and Neglect
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Abuse
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Neglect
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Multiple bruises in different stages of healing
Injury inconsistent with MOI
Repeated calls to the same location
Fresh burns
Parents seem inappropriately unconcerned
Conflicting stories
Fear on the part of the child to discus how they were hurt
S/S of Neglect
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Giving insufficient attention/respect to an individual who has a right to that attention
S/S of Abuse
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Improper or excessive action so as to injure or cause harm
Lack of adult supervision
Malnourished appearing child
Unsafe living environment
Untreated chronic illness
CNS injuries are the most lethal in the field (Shaken Baby Syndrome)
Do NOT accuse in the field
Required reporting by state law
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What you SEE and what you HEAR
NOT what you THINK

36. Virginia Child Abuse Hotline
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In State
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(800) 552-7096
Out of State
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(804) 786-8536

37. Special Needs Children
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Examples:
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Premature babies with lung disease
Babies and children with heart disease
Infants/children with neurological disease
Children with chronic diseases
Often these pt are at home technologically
dependant

38. Infants and Children
Special Needs Children
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Tracheostomy Tube
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Complications:
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Obstruction, Bleeding, Air leak, Dislodged, Infection
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Care:
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Maintain open airway
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Suction
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Maintain position of comfort
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Transport
Home Ventilators
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Care:
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Assure patency of airway
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Artificially ventilate with O2
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Transport
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The parents will be familiar with the equipment
Shunts
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Device running from brain to abd to drain excess CSF
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Will find reservoir on side of skull
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Be prepared for AMS
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Prone to resp arrest
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Manage airway
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Assure adequate ventilation
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Transport

41. Infants and Children
Special Needs Children
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Central Lines
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Complications
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Care
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Cracked line
Infection
Clotting off
Bleeding
If bleeding, apply pressure
Transport
Gastronomy Tube and Gastric Feeding
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Tube inserted directly into stomach for feeding
Be alert for breathing problems:
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Assure adequate airway
Have suction ready
If diabetic Hx, anticipate AMS
O2
Transport
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Sitting
Lying on Right side, head elevated

42. Family Response
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Multiple patients
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Calm, supportive interaction with
family
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Improves ability to deal with child
Calm parents = Calm child
Agitate parents = Agitate child
Parents may respond with
anger/hysteria
Allow parents to remain part of the
care unless condition does not
allow
Parents should instructed to calm
child
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Child cannot be cared for in
isolation from family
Transport in position of comfort
Hold O2, etc
Parents are EXPERTS on what is
normal and abnormal for their child

43. Provider Response
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Anxiety from lack of
experience
Fear of failure
Stress of identifying pt
with own child
Much of adult learning
applies to children
REMEMBER the
differences
PRACTICE

44. That does it…