1. The document provides information on assessing and managing pediatric patients in respiratory emergencies, trauma, shock, seizures, poisoning, and children with special healthcare needs. 2. Key differences in pediatric airway management include using a head-tilt chin-lift without hyperextension, appropriately sized equipment, and slower ventilation rates for children. 3. In trauma, maintaining the airway and providing high-flow oxygen are priorities, and injuries can be more severe even without obvious external signs. Special considerations are given to burns, spinal immobilization, and use of PASG devices.

1. Chapter
Twenty-Five
Infants and
Children

2. Chapter
CORE CONCEPTS
Twenty-Five
Pediatric respiratory
emergencies
Other pediatric medical
emergencies
Pediatric trauma

3. Newborns and Infants: Birth to 1 Year

4. Newborns and Infants
Very little anxiety from
exposure to strangers.
Dislike separation from
parents.
(Continued)

5. Newborns and Infants
Dislike feeling of oxygen mask
on face.
Need warmth:
• Warm hands and stethoscope
(Continued)

6. Newborns and Infants
Obtain respiratory rate from
a distance.
If listening to lungs, do it early
(before child becomes upset).
Examine head last to
build confidence.

7. Toddler: 1 to 3 Years

8. Toddlers
Dislike
Being touched
Separation from parents
Removal of clothing
(remove, examine, replace)
Feeling of oxygen mask
on face
(Continued)

9. Toddlers
Think illness/injury is punishment.
Afraid of needles, pain.
Examine trunk first, head last.

10. Preschool: 3 to 6 Years

11. Preschoolers
Dislike
Being touched
Separation from parents
Removal of clothing
(remove, examine, replace)
Feeling of oxygen mask
on face
(Continued)

12. Preschoolers
Think illness/injury is punishment.
Afraid of blood, pain,
permanent injury.
Modest.
Have magical thoughts.

13. School Age: 6 to 12 Years

14. School-Age Child
Afraid of blood and pain.
Afraid of permanent injury
and disfigurement.
Modest.

15. Adolescent: 12 to 18 Years

16. Adolescent
Afraid of permanent injury
and disfigurement.
Modest.
Treat as an adult.
Examine in private if possible
(away from adults).

17. Airway Differences between
Adults and Children

18. Airway Differences between
Adults and Children
Small airways are more easily
blocked.
Child's tongue is larger.
Infants are nose breathers.
• Suctioning nasopharynx improves
breathing significantly.
(Continued)

19. Airway Differences between
Adults and Children
Put child’s head in neutral position,
not hyperextended.
Children can compensate (breathe
faster/harder) for a while, then
get worse rapidly.

20. Opening the airway Use head-tilt,
chin-lift procedure without hyperextension.

21. Suctioning
Ensure small enough catheter.
Do not insert too deeply.
Suction as briefly as possible.

22. Treating Mild Airway
Obstruction
Place in position of comfort
(parent’s lap okay).
Administer high-concentration
oxygen.
Transport without agitating.

23. Severe Airway
Obstruction
No crying or speech
Initial difficulty breathing that
worsens
Cough becomes weak and ineffective
Altered mental status,
unconsciousness

24. Clearing Foreign Body
Obstructions
INFANTS
CHILDREN
Back blows and Abdominal
chest thrusts
thrusts
Remove visible foreign body.
Attempt artificial ventilation with BVM.

25. Oral Airways
Use correct size.
Use tongue depressor to hold down tongue.
Insert right side up (not upside down).

26. Nasal Airways
Use proper size.
Insertion technique is same
as for adult.

27. Nonrebreather Mask

28. Blow-By Technique
Hold tubing 2 inches from face,
OR
Insert tubing into paper
cup. Do not use
styrofoam cup.

29. Artificial Ventilation
Use proper size mask and bag.
If trauma is involved, use jaw
thrust (not head tilt).
If unable to maintain mask seal
with one hand, use two.
(Continued)

30. Mouth-to-Mask Ventilation

31. Artificial Ventilation
Bag-Mask Device:
• Squeeze bag slowly/evenly until chest rises.
• From birth to puberty (about 12 years old),
• ventilate 12–20 times a minute, each lasting
1 second.
• If the patient has reached puberty, ventilate
10–12 times a minute, each lasting 1 second.
• Use oxygen reservoir to provide 100%
oxygen.

32. Assessment: General Impression
Observe:
• Mental status
• Breathing
• Color
Observe:
• Quality of cry or speech
• Emotional state
• Response to your presence
• Tone and body position
(Continued)

33. Assessment: General Impression
Observe:
• Interaction with environment
and parents
Normal behavior for age?
• Playing or moving around?
• Attentive?
• Eye contact?
• Recognize and respond to parents?
•

34. Approach to Evaluation
As soon as you see patient, check:
• Mechanism of injury
• Surroundings
• Healthy or sick appearance
(Continued)

35. Approach to Evaluation
Assess respirations:
• Chest expansion and symmetry
• Effort of breathing
• Nasal flaring
• Retractions
(Continued)

36. Approach to Evaluation
Assess respirations:
• Crowing or noisy respirations
• Stridor
• Grunting
• Respiratory rate
Assess perfusion:
• Skin color (CTC)
(Continued)

37. Approach to Evaluation
When you reach child,
continue breathing assessment
using stethoscope:
• Breath sounds present or absent?
• Stridor?
• Wheezing?
(Continued)

38. Approach to Evaluation
Assess circulation:
• Brachial or femoral pulse
• Peripheral pulses
• Capillary refill
• Blood pressure (if over age 3)
• Skin color, temperature, condition

39. Detailed Physical Exam
Generally start at trunk and
evaluate head last.
Alter order of steps to fit situation.
Avoid making child more anxious.

40. PEDIATRIC
RESPIRATORY
EMERGENCIES

41. Patient ASSESSMENT
Partial Airway Obstruction
Signs and Symptoms
Stridorous, crowing, or noisy
respirations
Retractions on inspiration
Pink mucous membranes and
nail beds
Alert

42. Patient CARE
Partial Airway Obstruction
Emergency Care Steps
Allow position of comfort
(parent’s lap okay).
Do not lay child flat.
Offer high-concentration oxygen.
Transport without agitating.
(Do not assess blood pressure.)

43. Patient ASSESSMENT
Complete Airway Obstruction
Signs and Symptoms
No crying or speech
Initial breathing difficulty that worsens
Cough becomes weak and ineffective
Altered mental status, unconsciousness

44. Patient CARE
Complete Airway Obstruction
Emergency Care Steps
Clear airway with infant/child
foreign body procedures.
Attempt artificial ventilation with
BVM. Assure good seal between
mask and face.

45. Respiratory Emergencies
Upper airway obstruction
• Stridor on inspiration
Lower airway disease
• Wheezing and respiratory effort on
exhalation OR rapid breathing
without stridor

46. PRECEPTOR PEARL
Tell new EMT-Bs that pediatric care experts
emphasize that the priority of children in
respiratory distress is “AAA,” not just
“ABC.” In other words, if you manage the
patient’s airway and oxygenate, circulation
improvement will follow!

47. Patient ASSESSMENT
Early Respiratory Distress
Signs and Symptoms
Nasal flaring
Retractions
• Between ribs (intercostal)
• Above clavicles (supraclavicular)
• Below ribs (subcostal)
(Continued)

48. Patient ASSESSMENT
Early Respiratory Distress
Signs and Symptoms
Stridor
Retractions of neck,
abdominal muscles
Audible wheezing
Grunting
(Continued)

49. Patient ASSESSMENT
Early Respiratory Distress
Signs and Symptoms
Respiratory rate > 60/minute
Cyanosis
Decreased muscle tone
Excessive use of accessory muscles

50. Patient ASSESSMENT
Respiratory Distress
Signs and Symptoms
Poor peripheral perfusion
Altered mental status
Grunting

51. Patient ASSESSMENT
Respiratory Arrest
Signs and Symptoms
Respiratory rate < 10/minute
Little or no muscle tone
Unconsciousness
Slow/absent heart rate
Weak/absent pulse

52. Signs of Respiratory Distress

53. Patient CARE
Respiratory Emergencies
Emergency Care Steps
Administer high-concentration oxygen.
Ventilate if respiratory distress is severe:
• Altered mental status
• Cyanosis not improving with oxygen
• Poor muscle tone
• Respiratory failure
• Respiratory arrest

54. PEDIATRIC
TRAUMA

55. Trauma
In the United States, injuries kill
more children and infants than
any other cause of death.

56. Blunt Trauma
(Most Common Type of Injury)
Motor vehicle crashes
• Unrestrained passenger head and
neck injuries
• Restrained passenger abdominal
and lower spine injuries
(Continued)

57. Blunt Trauma
Motor vehicle crashes
• Struck while riding bicycle
(head, spine, abdominal injuries)
• Pedestrian struck by vehicle
(abdominal, femur, head injuries)
(Continued)

58. Blunt Trauma
Falls from height
• Head and neck injuries
Diving into shallow water
• Head and neck injuries
Burns
Sports injuries
Child abuse

59. Blunt Trauma
Specific Types of Injuries
Head
• Airway maintenance is critical.
• Head injury is common.
• Can result in respiratory arrest.
• Nausea and vomiting are common.
(Continued)

60. Blunt Trauma
Specific Types of Injuries
Chest
• Children’s ribs are less rigid than
adults’ ribs.
• Result in injury to internal organs
without external wounds.
(Continued)

61. Blunt Trauma
Specific Types of Injuries
Abdomen
• More commonly injured in children
than adults.
• May be subtle and difficult to detect.
• Under stress, children swallow air
(may cause gastric distention, impede
breathing).
(Continued)

62. Blunt Trauma
Specific Types of Injuries
Extremities
• Managed the same as adults

63. Trauma
Other Considerations
Pneumatic Antishock Garment
• Use only if:
Child fits in garment.
• Trauma occurs with hypoperfusion
and pelvic instability.
•
• Do not inflate abdominal compartment.
(Continued)

64. Trauma
Other Considerations
Burns
• Cover with sterile dressing
(sterile sheet works well).
• Follow local protocol with regard to
transport to burn center.

65. Patient CARE
Trauma
Emergency Care Steps
Establish and maintain airway with
jaw thrust.
Suction and ventilate as needed.
Provide high-concentration oxygen.
Immobilize spine.
Transport.

66. Shock (Hypoperfusion)
Causes
Uncommon
Causes
Diarrhea, vomiting, dehydration
Trauma and blood loss
Infection
Abdominal injuries
Allergic reactions
Poisoning
Cardiac problems

67. PRECEPTOR PEARL
Tell new EMT-Bs that one way
to remember how little blood
children have is to envision that an
infant’s total blood volume would
fill only a soda can and a school
age child’s a six-pack.

68. Patient ASSESSMENT
Shock (Hypoperfusion)
Signs and Symptoms
Rapid breathing
Pale, cool, clammy skin
Weak/absent peripheral pulses
Delayed capillary refill
(Continued)

69. Patient ASSESSMENT
Shock (Hypoperfusion)
Signs and Symptoms
Decreased urine output
Inspect diaper/ask parents when last changed.
Changes in mental status
Lack of tears when crying

70. Signs of Shock (Hypoperfusion)

71. Patient CARE
Shock (Hypoperfusion)
Emergency Care Steps
Assure airway and give
high-concentration oxygen.
Ventilate as needed.
Control bleeding.
Elevate legs.
Keep warm.
Transport promptly.

72. Patient CARE
Near Drowning (submersion)
Emergency Care Steps
Ventilation is top priority.
Consider possibilities of trauma,
hypothermia, and drug ingestion
(especially alcohol in teenagers).
Transport. (Some patients deteriorate
minutes/hours later.)

73. KEY TERMS
Abuse
Improper or excessive action so as to
injure or cause harm
Neglect
Giving insufficient attention or respect
to someone who has a claim to that
attention

74. Physical abuse and neglect are
forms of child abuse EMT-B
is most likely to suspect.
EMT-B must be aware of
condition in order to
recognize it.

75. PRECEPTOR PEARL
Tell new EMT-Bs that the ED physician is
required to report cases of child abuse.
Therefore, they should complete the PCR with
factual information that they observed about
the child’s home environment, the condition of
the home, the reaction of the parents or other
caretakers, the child’s hygiene, and general
interaction of all family members involved,
and call it to the attention of the physician.

76. Patient ASSESSMENT
Abuse
Signs and Symptoms
Multiple bruises in different stages
of healing
Injury inconsistent with
mechanism described
Repeated calls to same address
(Continued)

77. Patient ASSESSMENT
Abuse
Signs and Symptoms
Fresh burns
Apparent lack of enough concern
in parents
Conflicting stories
Child’s hesitancy to describe how
injury occurred

78. Patient ASSESSMENT
Neglect
Signs and Symptoms
Lack of adult supervision
Apparent malnourishment
Unsafe living environment
Untreated chronic illness

79. Handling Abuse and Neglect
Head injuries are most lethal
(shaken baby syndrome).
Do not accuse anyone in the field.
(Continued)

80. Handling Abuse and Neglect
Required reporting
• Follow state laws and local regulations.
• Document objective information: what
you SEE and HEAR, not what you merely THINK.

81. PEDIATRIC
MEDICAL
EMERGENCIES

82. Seizures
Rarely life-threatening in
children, but EMT-B should
take seriously.
May be brief or prolonged.
May cause injuries.

83. Seizures
Causes
Fever
Infection
Poisoning
Hypoglycemia
Trauma
Hypoxia
Idiopathic
(unknown cause)

84. Patient ASSESSMENT
Child after Seizure
Signs and Symptoms
Has child had seizures before?
If yes, was this typical seizure?
Was antiseizure medication taken?

85. Patient CARE
Seizures
Emergency Care Steps
Establish airway.
Position on left side if no spine trauma.
Have suction ready.
Give oxygen. Ventilate if respiratory
distress/arrest.
Transport.

86. Altered Mental Status
Causes
Hypoglycemia
Poisoning
Postseizure
Infection
Head trauma
Hypoxia
Shock

87. Patient CARE
Altered Mental Status
Emergency Care Steps
Establish airway.
Ventilate and suction as needed.
Transport.

88. Patient CARE
Poisoning: Responsive Patient
Emergency Care Steps
Contact medical direction.
Give activated charcoal as directed.
Administer oxygen.
Transport and monitor patient.

89. Patient CARE
Poisoning: Unresponsive Patient
Emergency Care Steps
Rule out trauma.
Establish airway.
Administer oxygen; ventilate
as needed.
Contact medical direction.
Transport.

90. Fever
Many things can cause fever.
Meningitis is one of worst. May
appear as fever with rash.
Transport.
Be prepared for seizures.

91. Sudden Infant Death
Syndrome (SIDS)
Sudden death occurs without
identifiable cause in infant
< 1 year old.
Cause is not well understood.
Most common time of discovery
is early morning.

92. Patient CARE
SIDS
Emergency Care Steps
Try to resuscitate unless rigor
mortis is present.
Avoid comments that blame parents.
Expect parents to feel remorse and guilt.

93. INFANTS AND
CHILDREN WITH
SPECIAL NEEDS

94. Children with Special Needs
Premature babies with lung disease
Heart disease
Neurologic disease
Chronic disease or altered function
since birth

95. Technologically Dependent
Children (“High-Tech Kids”)
Tracheostomy tube
Central intravenous lines
Gastrostomy tubes
Shunts

96. Tracheostomy Tube
Complications
Obstruction
Bleeding
Air leak
Dislodged tube
Infection

97. Patient CARE
Tracheostomy Tube
Emergency Care Steps
Maintain open airway.
Suction.
Maintain position of comfort.
Transport.

98. Home Artificial Ventilation
Parents are usually very
familiar with equipment.

99. Patient CARE
Home Artificial Ventilation
Emergency Care Steps
Assure airway.
Artificially ventilate with
high-concentration oxygen.
Transport.

100. Central Intravenous Lines
IVs that are very long
• Tip in vein near heart
Complications
• Cracked line
• Infection
• Clotting off
• Bleeding

101. Patient CARE
Central Intravenous Lines
Emergency Care Steps
If bleeding, apply pressure.
Transport.

102. KEY TERMS
Shunt
Tube running from brain to abdomen
to drain excess cerebrospinal fluid
Gastrostomy Tube
Tube placed directly into the stomach for a
child who cannot be fed by mouth

103. Patient CARE
Shunt
Emergency Care Steps
Assure airway and ventilate as needed.
Transport.

104. Patient CARE
Gastrostomy Tube
Emergency Care Steps
Assure patent airway.
Suction as needed.
Provide high-concentration oxygen.
Transport patient sitting or lying on
right side with head elevated.

105. REVIEW QUESTIONS
1. Describe two characteristics of a
typical child in each of the five
age groups.
2. Describe the management of pediatric
respiratory distress.
3. How do children compensate for
blood
loss compared to an adult?
4. What are some indications of